Comparison between free wrist crease flap pedicled with superficial palmar branch of radial artery and traditional free toe flap in reconstruction of hand soft tissue defects: A study on clinical efficacy / 中华显微外科杂志

Objective:To compare the difference in clinical efficacy between a free wrist crease flap pedicled with superficial palmar branch of the radial artery flap (SPBRAF) and a traditional free toe flap (TFTF) in reconstruction of hand soft tissue defects, and to provide reference for the treatment of small-to medium-sized hand soft tissue defects.Methods:Data of 37 patients who received hand surgery in Department of Hand Surgery, No.971 Hospital of the PLA Navy from December 2016 to December 2019 for small-to medium-sized hand soft tissue defects were retrospectively studied. Among the 37 patients, there were 32 males and 5 females, aged between 18 and 65 years old, with 41.5 years old in average. According to the reconstructive surgical procedure, patients were divided into SPBRAF group (22 cases) and TFTF group (15 cases). Regular follow-ups were conducted after surgery. The difference in curative effect at the last follow-up between the 2 groups was evaluated by the comparison of data acquired in follow-up. SPSS 25.0 was used to analyse the data statistically. The evaluation indicators included flap survival, long-term recovery of flap, recovery effect at donor site, total active movement(TAM) of the affected digit, time of hospital stay and the time return to work. P<0.05 was considered a statistically significant. Results:All free flaps survived. All patients were entered 6-18 (mean, 10) months of postoperative follow-up to comprehensively evaluate the therapeutic effect. According to the Evaluation Trial Standards of Upper Limb Partial Function of Hand Surgery of Chinese Medical Association, in the SPBRAF group, 20 flaps were found in excellent, and 2 in good; in the TFTF group, 14 flaps were found in excellent, 1 in good. There was no statistical difference between the 2 groups( P>0.05). The colour, texture and thickness of flaps between the 2 groups were either in excellent or good. There was no statistical difference between the 2 groups( P>0.05). TPD in the TFTF group (5-6 mm) was better than that in SPBRAF group (6-7 mm) with statistical difference between the 2 groups ( P<0.05). Texture at donor sites between the 2 groups was either in excellent or good ( P>0.05). In terms of appearance, sensation and recovery time of donor site, it was found that the SPBRAF group(mean, 6 weeks) was significantly better than those in the TFTF group(mean, 8 weeks) and there was statistical difference between the 2 groups ( P<0.05). In terms of recovery of TAM in single-digit, excellent or good were shown in both groups and there was no statistical difference between the 2 groups ( P>0.05). In terms of hospitalisation and time for return to work, the SPBRAF group(mean, 8 days and 17 weeks) was significantly better than that of TFTF group(mean, 12 days and 24 weeks), and there was statistical difference between the 2 groups ( P<0.05). Conclusion:SPBRAF has an ideal effect on reconstruction of small-to medium-sized hand soft tissue defects in hand. Although the flap is still inferior in sensation and appearance compared with the TFTF, the advantages in terms of donor site recovery, patient satisfaction of the donor site and reduced time of hospitalisation and return to original work are more obvious. SPBRAF provides a good complement to surgical procedures reconstructing a digit defect.

Reconstruction of finger C-shape soft tissue defect with wrist crease free flap carrying cutaneous nerve / 中华显微外科杂志

Objective:To explore clinical results in reconstruction of finger C-shape soft tissue defect with the wrist crease free flap carrying cutaneous nerve.Methods:From June, 2017 to April, 2019, 7 fingers(7 patients) with C-shape defect were treated with the wrist crease free flap carrying cutaneous nerve. The size of defect ranged from 1.0 cm × 2.5 cm-2.2 cm × 4.0 cm; the flap sizes were 1.3 cm × 2.7 cm-2.5 cm × 4.5 cm. Five fingers had unilateral defect of proper palmar digital artery. Two fingers that had bilateral defect of proper palmar digital artery with poor blood circulation were re-established with blood supply by Flow-through flaps. Four fingers had unilateral defect of proper palmar digital nerves, and 3 had bilateral defect of proper palmar digital artery. Five of the fingers were repaired by the superficial branch of the radial nerve and 2 repaired by palmar cutaneous branch of median nerve. Regular outpatient follow-up was conducted after surgery for 8 to 15 (mean 11) months.Results:All the fingers and flaps survived with primary healing. Numbness existed in the areas of functional dominance of the cutaneous nerve. At the end of follow-up, the flaps showed good texture without significant bloated appearance with the recovery of protective sensation. The sensation of fingertip recovered to S 4 in 5 fingers and S 3+ in 2 fingers. Finger pulps were plump. All of the fingers moved freely. Linear scars were observed at donor sites and the wrists moved freely. Numbness feeling in the areas of cutaneous nerve disappeared at 6 to 8 weeks after surgery. According to the Functional Evaluation Criteria of the Finger Replantation published by the Hand Surgery Society of the Chinese Medical Association, the results were excellent in 6 fingers and good in 1 finger. Conclusion:The wrist crease free flap carrying cutaneous nerve is constant and can be dissected transversely to reconstruct and fit the C-shape defect of finger. It can re-establish the blood supply as well as to repair the proper palmar digital nerve defect at the same time.

The free neurovascular transverse wrist crease flap for repairing soft tissue defects of the fingers: clinical outcomes of multiple centers.

BACKGROUND: Flap transplantation is often needed for soft tissue defects of the fingers that cannot be closed directly. Sensory reconstruction of the fingers is important for patients to recover feelings. In this study, we report clinical outcomes of using free neurovascular transverse wrist crease flap for repairing finger defects from multiple centers. METHODS: This case series includes 72 consecutive patients with finger defects between June 2013 and June 2016 from multiple centers. A neurovascular transverse free radial artery superficial palmar branch flap, named transverse wrist crease flap, was designed to reconstruct soft tissue defects of the fingers with microvascular anastomosis. When there were soft tissue defects of the fingers with digital nerve defect, end-to-end neurorrhaphy between the median palmar cutaneous branch and the digital nerves was also performed. The donor incision was sutured directly. All the patients were followed-up for more than 24 months. RESULTS: The soft tissue defects of the fingers were all completely covered with this free neurovascular transverse wrist crease flap, and the flaps in 71 patients survived completely without ischemia. Vascular crisis appeared in one case, and the wound healed gradually after changing wound dressing for nearly 1 month. Slight infections of wounds appeared in eight cases. There were no complications in the donor site, like infection and poor wound healing. At the last follow-up, the mean static two-point discrimination was 9.6 ± 2.4 mm on the injured finger and 4.5 ± 0.8 on the contralateral corresponding finger. The motion range of the distal interphalangeal joint and proximal interphalangeal joint on the injured finger were 72.5 ± 23.3% and 78.7 ± 32.5% of the contralateral corresponding finger, respectively. Patient self-evaluations were good in 53 cases and fair in 19 cases. CONCLUSIONS: The results indicate that the free neurovascular transverse wrist crease flap is a good choice for repairing soft tissue defects of the fingers. LEVEL OF EVIDENCE: Therapeutic IV.

The anatomical basis and clinical application of free wrist crease flap / 中华显微外科杂志

Objective To summarize the cutaneous branches of the superficial branch of radial artery distribution were dissected and to discuss the operational technique and clinical efficacy of repairing hand tissue defect by the flap based on the superficial branch of radial artery.Methods From May,2014 to February,2017,8 fresh hand specimens perfused with red latex to observe the distribution and characteristics.And 24 cases of fingers tissue defects (3 thumbs,6 index fingers,5 middle fingers,9 ring fingers,and 1 litter finger) which were repaired with the free wrist crease flap based on the cutaneous branches of superficial palmar branch of the radial artery.Combined fracture in 5 cases.Combined rupture or defect of the flexor tendon in 8 cases.Combined vascular nerve injury in 6 cases.The maximum area of the flap was 5.5 cm × 3.2 cm,and the minimum was 2.0 cm × 1.5 cm.Regular followedup was performed after operation.Results Superficial palmar branch of the radial artery came from the level of radial styloid process ulnar palmar then through ulnar of tubercle of scaphoideum and tended to the thenar muscle.It gave 1-3 branches of the direct skin perforators at distal wrist crease and the anatomical location was constant.The vascular pedicle length could achieve 2.0-3.2 cm.All flaps were survived uneventfully.Twenty-four cases were followed-up for 6-29 months (mean,18.6 months),and the appearance and functional recovered satisfactorily.Flap sensation recovered to S3+.The 2 point discrimination was 8-13 mm.There was no complication in donor area.According to the fingers total active motion (TAM) method to assess:excellent in 17 cases,good in 5 cases,fair in 2 cases.The excellent and good rate was 91.7％.Conclusion The wrist crease cutaneous branches of superficial palmar branch of the radial artery anatomical location is constant.And the flap based on the artery has a reliable blood supply.The vascular pedicle flap is long enough and the operational technique is easy and safe.The postoperative effect is satisfied.It is an ideal method for repairing finger tissue defect.

Technical Points of 5 Free Vascularized Flaps for the Hand Repairs.

In this article, we present the experiences from Chinese microsurgeons on 5 less commonly used free vascularized flaps in hand reconstruction. In many units in China, these flaps have become the mainstays of treatment; they are routinely used for fingertip and thumb reconstruction. Their combined experience has demonstrated the reliability and versatility of these flaps for hand reconstruction, as well as their cosmetic value.

[Clinical observation of superficial branch of radial artery wrist crease flap for repairing ring tissue defect of fingers].

Objective: To explore the effectiveness and operation method of the superficial branch of radial artery wrist crease flap for repair of ring tissue defect of the fingers. Methods: Between June 2013 and March 2016, the superficial branch of radial artery wrist crease flap was used to repair ring finger tissue defect in 20 cases (21 fingers). There were 14 males and 6 females with an average age of 39.3 years (range, 12-61 years). The causes included machine injury in 9 cases, traffic accident injury in 6 cases, heat inury in 2 cases, and avulsed injury in 3 cases. The index finger was involved in 6 cases, middle finger in 6 cases, ring finger in 3 cases, and little finger in 6 cases. Combined injuries included exposure of bone, tendon, vessel, and nerve. The mean time of injury to operation was 3 hours (range, 0.5-5.5 hours) in 17 patients undergoing emergency operation, and was 8.5 days (range, 7-10 days) in 3 patients undergoing selective operation. The superficial palmar branch of the radial artery from the flap was used for bridging proper digital artery. The donor site was directly sutured in 19 cases and was repaired by skin grafting in 1 case. Results: One case had blood blister at distal flap, which was cured after dressing change; the other flaps survived, and primary healing was obtained. Healing of incision at the donor site healed by first intention. The patients were followed up 6-24 months (mean, 12 months). The appearance, texture, and color of the flaps were satisfactory. The two-point discrimination ranged from 6 to 13 mm (mean, 9 mm) at 6 months after operation. According to the Chinese Medical Association Society of hand surgery of thumb and finger reconstruction function evaluation standard, the results were excellent in 13 cases, good in 4 cases, and fair in 3 cases; the excellent and good rate was 85%. Conclusion: The superficial branch of radial artery wrist crease flap is an ideal choice for the repair of ring tissue defect of the fingers.