Soft tissue reconstruction of thumb: Classification of defects and standardization of treatment.

OBJECTIVE: 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. METHODOLOGY: 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. RESULTS: 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. CONCLUSION: 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.

Is the dorsal vascular system sufficient to vascularize the entire teguments of the thumb?

PURPOSE: Simultaneous lesions of both proper digital arteries of the thumb are common in hand trauma surgery. The purpose of this anatomical study was to determine if the dorsal arterial network could be sufficient to ensure the vascularization of the thumb skin sheath. METHODS: We carried out a cadaveric study on 22 hands. The ulnar and radial proper digital arteries of the thumb were ligated at the base of the first phalanx. Red dye was injected into the radial artery and blue dye into the ulnar artery at the wrist level. Visual evaluation of skin staining and systematic photographs was done at 1, 3 and 10 min after injection of dyes. RESULTS: Staining of the thumb sheath was obtained in 100% of the dissections and complete in 91.91% of cases. Staining originated from mixed radial and ulnar artery origins in 81.82% of cases. It was incomplete in 9.09% of cases with a missing on the dorsoradial edge of the proximal phalanx. In one dissection, the whole hand skin was only stained red, and in another dissection only stained blue. CONCLUSION: The dorsal vascular network ensures the substitution of the skin vascularization in more than 90% of cases when ligating the proper digital arteries of the thumb. A clinical impression of good skin vascularization after injury of both proper digital arteries might lead the surgeon not to perform systematic revascularization, but the risk of variable damages of adjacent tissues due to an interruption of one major arterial system requires a palmar arterial anastomosis whenever possible.

[Transplantation of compound tissue flap of toe to reconstruct the thumb with necrosis caused by electric burns in four patients].

From January 2010 to December 2017, 4 patients of thumb with necrosis caused by electric burns (all male, aged from 31 to 58 years) were admitted to our hospital, with 1 patient of second degree injury of right thumb, 2 patients of third degree injury of right thumb, and 1 patient of third degree injury of left thumb. Routine debridement under general anesthesia was performed within 7 days after injury. The compound tissue flap of contralateral second toe was transplanted to reconstruct the thumb with third degree defect, and compound tissue flap of ipsilateral distal hallex was transplanted to reconstruct the thumb with second degree defect. Dorsalis pedics artery was anastomosed with radial artery, saphenous vein or dorsalis pedics vein was anastomosed with cephalic vein. The donor site was transplanted with split-thickness skin graft from autologous thigh. All the tissue flaps and skin grafts survived in 2 weeks after surgery. Within 1 year of follow-up, the reconstructed thumbs can achieve radial abduction and palmar abduction with good function. Reconstruction of thumb with free transplantation of compound tissue flap of toe is a good method to repair thumb with necrosis caused by electric burn.

Cross-finger subdermal pocketplasty as a salvage procedure for thumb tip replantation without vascular anastomosis: a case report.

Objectives Fingertip amputation is often encountered in emergency departments, especially in hospitals located near industrial areas. Replantation of the fingertip can be considered when the normal architecture is preserved in cases of sharp amputation. The goal of replantation is to preserve cosmesis and function, especially for the thumb because of its involvement in grasping and the key pinch. Even when microsurgical vascular anastomosis is applied, the absence of venous anastomosis along with the high rate of failure of arterial anastomosis in zone 1A fingertip amputation may lead to replantation failure. Methods We herein present a case report of thumb tip amputation salvaged via a modified cross-finger technique. The recipient site was on the ipsilateral radial side of the intermediate phalanx of the middle finger. Results The thumb tip was successfully replanted with no vascular anastomosis, and this new technique prevented stiffness in the metacarpophalangeal and interphalangeal joints of the thumb and middle finger. Conclusions This procedure can be performed in local clinics and emergency departments without the need for arterial and venous anastomoses.

Ulnar Thumb Pulp Reconstruction Using the Anterograde Homodigital Neurovascular Island Flap.

The thumb ulnar pulp is a critical component of key pinch and precision manipulation. Injuries to this area should be reconstructed with robust, sensate tissue that restores bulk and contour. The existing reconstructive options, however, have substantial risks and drawbacks. We describe an anterograde homodigital neurovascular island flap that provides both sensate and durable coverage of the ulnar thumb pulp. The flap uses innervated glabrous tissue, limits donor site morbidity to the thumb and first web space, and does not require microvascular anastomoses or nerve coaptation. The flap has been previously described for nonthumb fingertip injuries, but it has not been applied to the thumb. We discuss several important technical modifications that are essential to raising and insetting this flap in the thumb, review potential pitfalls, and highlight key steps to ensuring judicious intraoperative decision making and success.

Venous Bridge Arterial Grafting for Thumb Replantation.

BACKGROUND: The purpose of this study is to describe a novel technique using an interposition vein graft for thumb replantation in these severe avulsion injuries. METHODS: From 2002 to 2012, 8 patients underwent interposition venous bridge grafting from the dorsal radial artery at the anatomic snuffbox to the ulnar digital artery of the thumb. All patients had a traumatic thumb amputation with a severe injury to the ulnar digital artery. The technique began with bony stabilization; the radial artery at the anatomic snuffbox is exposed, vein graft harvested, and microsurgical end-to-side (proximally) and end-to-end (distally) anastomoses are carried out. RESULTS: The average time to the operating room was 7.4 hours and time to reperfusion was 9.5 hours. At 3.1 years of follow-up, all 8 thumbs remained viable, without any need for revision procedures. The only complication was a metacarpal shaft nonunion treated successfully with iliac crest bone grafting. At last follow-up, all patients reported no or mild pain, with an average metacarpophalangeal (MCP) range of motion of 46.5°, and intact but diminished 2-point discrimination. All patients were able to return to work full-time. CONCLUSIONS: Due to the challenging nature of thumb avulsion injuries and the pronated position of the thumb, novel salvage alternatives are important. We describe a technique when no proximal vessels are available, using a vein to bridge the dorsal radial artery to the ulnar digital artery of the thumb. This novel arterial reconstruction has shown promise in thumb replantation associated with severe avulsion injuries.

Reverse Radial Forearm Flap to Provide Arterial Inflow to a Toe Transfer.

Background: Toe-to-thumb transfer has become the gold standard for thumb reconstruction, but in badly mutilated hands, additional soft tissue coverage may be required or a suitable recipient artery may not be available. There are only 3 case reports describing the successful use of a reverse radial forearm flap for coverage of a soft tissue defect around the thumb as well as providing arterial inflow for a toe transfer, performed either simultaneously or secondarily. Methods: A single surgeon's experience of all toe-to-hand transfers performed in conjunction with a reverse radial forearm flap between 1995 and 2014 was reviewed, including patient demographics, type of toe transfer and vascular pedicle, whether immediate or secondary, follow-up, and complications. Results: Eight toe-to-hand transfers were performed in 7 patients-3 children (age range, 3-15 years) and 4 adults (age range, 19-39 years). Three patients underwent primary toe-to-thumb transfer simultaneously with a reverse radial forearm flap, and 5 patients underwent secondary toe-to-hand transfer between 4 months and 2½ years after an initial reverse radial forearm flap. All toe transfers survived completely. Average follow-up was 5.1 years. All patients were satisfied with the function and appearance of their reconstructed thumb. Conclusion: The reverse radial forearm flap is a very reliable procedure as a "Sister" or "Siamese" flap to provide immediate arterial inflow to a simultaneous toe-to-thumb transfer, or to provide primary soft tissue coverage on the radial aspect of the hand and subsequently provide a recipient arterial inflow for a secondary toe transfer.

[Vascular crisis after multiple tissue transplantation for thumb and other finger reconstruction by toe-to-hand transfer].

Objective: To explore the causes of vascular crisis after thumb and other finger reconstruction by toe-to-hand transfer and effective treatment methods so as to improve the survival rate of transplanted tissues. Methods: Between February 2012 and October 2015, 59 cases of thumb and other finger defects were repaired with different hallux nail flaps with the same vascular pedicle flap to reconstruct thumb and other fingers and repair skin defect. The donor site was repaired by a perforator flap. A total of 197 free tissues were involved. There were 46 males and 13 females with the average age of 30.6 years (range, 18-42 years). Vascular crisis occurred in 21 free tissues (10.7%) of 17 patients, including 9 arterial crisis (4.6%) of 8 cases, and 12 venous crisis (6.1%) of 10 cases. Conservative treatment was performed first; in 8 free tissues of 7 cases after failure of conservative treatment, anastomotic thrombosis was found in 5 free tissues of 4 cases, twisted vascular pedicle in 1 free tissue of 1 case, surrounding hematoma in 1 free tissue of 1 case, and anastomotic thrombosis associated with hematoma in 1 free tissue of 1 case, which underwent clearing hematoma, resecting embolization, regulating vascular tension, re-anastomosis or vascular transplantation. Results: In 8 cases of arterial crisis, 5 free tissues of 5 cases survived after conservative treatment; partial necrosis occurred in 1 free tissue (1 case) of 4 free tissues (3 cases) undergoing surgical exploration. In 10 cases of venous crisis, 1 free tissue necrosis and 1 free tissue partial necrosis occurred in 8 free tissues (6 cases) undergoing conservative treatment; partial necrosis occurred in 1 free tissue of 4 free tissues (4 cases) undergoing surgical exploration. Free flap and skin graft were performed on 2 free tissues of 4 cases having flap necrosis respectively. Conclusion: Vascular crisis is complex and harmful to survival of transplanted tissue in reconstruction of the thumb and other fingers. Immediate intervention is helpful to obtain a higher survival rate.

Computed Tomography Angiography Allows the Classification of the First Dorsal Metatarsal Arteries.

Background Conventional angiography is an invasive technique. Submillimeter computed tomography angiography (CTA) has been shown to be an effective alternative for peripheral artery branches. This study aimed to assess the use of CTA to guide the choice and design of foot donor area for finger or thumb reconstruction. Methods This was a retrospective study of 79 patients who underwent finger or thumb reconstruction between January, 2011 and March, 2014. All these patients underwent preoperative CTA to determine the exact blood supply at the donor site. Preoperative imaging and intraoperative findings at the donor site were compared. Results Among the 79 patients (158 feet), 474 artery segments (dorsalis pedis artery [DPA], first dorsal metatarsal artery [FDMA], and toe web artery [TWA]) were evaluated using CTA. Image satisfaction rates of the vessels were 100.0 ± 0.0%, 89.2 ± 3.2%, and 60.1 ± 5.0% for DPA, FDMA, and TWA, respectively. Among the 158 feet, 90 were Gilbert type I (57.0%), 52 were Gilbert type II (32.9%), 13 were Gilbert type III (8.2%), and 3 were with poor visibility and could not be classified (1.9%). In all 79 patients, the CTA image of the FDMA was consistent with the intraoperative observations. All reconstructed fingers survived. Follow-up was available for 69 patients. After a 6- to 18-month follow-up, the reconstructed fingers and donor area recovered well, and the reconstructed fingers had strong holding power, without pain. Conclusion CTA can produce three-dimensional images for extremity arteries, allowing the preoperative assessment of blood supply and planning of donor site.

Pollicization of the Second Metacarpal Based on Dorsal Metacarpal Arteries.

Blood supply to the index finger is maintained through volar (palmar arch) and dorsal (intermetacarpal arteries) vascular networks. In traditional index finger pollicization, blood supply is maintained on the volar palmar arch. In case of index finger loss at the metacarpophalangeal joint, remaining length of the second metacarpal is often not used for pollicization because the arc of rotation is limited on digital arteries. In this report, we present a surgical technique for the transfer of the index metacarpal to the thumb on the dorsal vascular network. This method adds no further morbidity and can be used as an alternative method of thumb reconstruction in cases in which the thumb and index fingers are amputated.

[DECOMPRESSION AND DIVERTING EFFECTS OF VASCULAR ANASTOMOSIS BASED ON DIGITAL ARTERIAL ARCH BRANCH IN REPLANTATION OF FREE FINGER-PULP].

OBJECTIVE: To investigate the decompression and diverting effects of vascular anastomosis based on the digital arterial arch branch in replantation of free finger-pulp in distal phalanges. METHODS: A retrospective analysis was performed on the clinical data of 12 patients (12 fingers) who underwent free finger-pulp replantation with anastomosis of proper palmar digital artery and the palmar digital artery arch branch in the distal end between December 2004 and March 2015. Of 12 cases, 9 were male and 3 were female, aged 15-39 years with an average of 32 years. The causes of injury included cutting injury in 4 cases, crush injury in 7 cases, and avulsion injury in 1 case. The thumb was involved in 2 cases, index finger in 4 cases, ring finger in 3 cases, middle finger in 1 case, and little finger in 2 cases. The free finger pulp ranged from 1.8 cm x 1.5 cm to 2.8 cmx2.0 cm. The time from injury to operation ranged from 1.5 to 11.0 hours, with an average of 5.7 hours. No arterial arch or proper palmar digital arteriae anastomosis was excluded. RESULTS: Free finger-pulp survived in 11 cases after operation; venous crisis occurred in 1 case at 2 days after operation, and was cured after symptomatic treatment. Nine cases were followed up 6-18 months with an average of 10 months. The finger-pulp had good appearance, clear fingerprint, and soft texture. The two-point discrimination was 3.1-6.0 mm, with an average of 4.6 mm at 6 months after operation. The function of finger flexion and extension was normal. And according to upper extremity functional evaluation standard by hand surgery branch of Chinese Medical Association, the results were excellent in 7 cases, and good in 2 cases. CONCLUSION: In the replantation of amputated pulp with insufficiency of venous blood outflow, the anastomosis of digital arterial arch branch in the distal end can decompress and shunt arterial blood, adjust blood inflow and outflow, and solve the problems of insufficient quantity of the vein and venous reflux disturbance.

Calcinosis preferentially affects the thumb compared to other fingers in patients with systemic sclerosis.

OBJECTIVES: Although Raynaud's phenomenon often spares the thumb, clinical experience suggests conversely that, in patients with systemic sclerosis (SSc), the thumb is frequently affected by calcinosis (as is demonstrated on plain radiographs). Our aim was to investigate the hypothesis that, in patients with SSc, thumbs are more commonly affected by calcinosis than other digits. METHOD: Sixty-eight hand radiographs with at least one area of calcinosis were identified. Each digit on both hands of each patient was assigned a severity score on a scale from 0 to 3 (0 = no calcinosis, 3 = most severe). The scoring was completed twice, including and excluding the metacarpals. RESULTS: Right hands were found to be associated with slightly higher scores than left hands [estimate 0.14, 95% confidence interval (CI) 0.03-0.26]. Scores were lower for other fingers compared to thumbs. There was strong evidence (p < 0.0001) of a trend of decreasing severity moving from the thumb to the little finger. There was no evidence that the pattern of severity across the fingers was different on left and right hands (p = 0.77). The results were similar whether or not metacarpals were included. CONCLUSIONS: The thumb is affected by calcinosis more than other digits, followed by the index finger. This observation provides insight into the pathogenesis of SSc-related calcinosis, which may relate more to repetitive trauma than to ischaemia.

[EFFECTIVENESS OF PART LONG THUMB EXTENSOR TENDON DORSAL ULNAR ARTERY CHIMERIC FLAP FOR REPAIR OF Doyle TYPE â ¢ MALLET FINGER OF THUMB].

OBJECTIVE: To investigate the effectiveness of part long thumb extensor tendon dorsal ulnar artery chimeric flap for repair of Doyle type Ⅲ mallet finger of thumb. METHODS: Between June 2013 and April 2015, 9 cases of Doyle type Ⅲ mallet finger of thumb were treated, which were caused by planer injury. There were 6 males and 3 females, aged from 15 to 65 years (mean, 36 years). The time from injury to operation was 3-8 hours (mean, 5 hours). All cases had interphalangeal joint dorsal skin and soft tissue defects of the thumb; the skin defects ranged from 2.0 cm×1.5 cm to 2.3 cm×2.3 cm; the extensor tendon defect ranged from 0.5 to 1.5 cm in length (mean, 1.0 cm). The part long thumb extensor tendon dorsal ulnar artery chimeric flap of 3.0 cm×2.5 cm to 3.5 cm×3.0 cm in size was used to reconstruct extensor tendon and wound. The donor site was repaired with nasopharyngeal fossa perforating branches pedicled V-Y relay flap. RESULTS: All flaps survived completely and incisions healed by first intention. All patients were followed up 4-12 months (mean, 6 months). The flaps had good color, texture, and contour. At 6 months after operation, the two-point discrimination of chimeric flap was 10-12 mm (mean, 11 mm), and two-point discrimination of relay flap was 12-14 mm (mean, 13 mm). The interphalangeal joint flexion of thumb was 0-40°, and the thumb opposition function was normal. CONCLUSIONS: Part long thumb extensor tendon dorsal ulnar artery chimeric flap can repair the Doyle type Ⅲ mallet finger of thumb, which has no injury to the artery and nerve. At the same time the relay flap can achieve linear healing, so good appearance and function of the thumb can be obtained.

[DORSALIS PEDIS FLAP SERIES-PARALLEL BIG TOE NAIL COMPOSITE TISSUE FLAP TO REPAIR HAND SKIN OF DEGLOVING INJURY WITH THUMB DEFECT].

OBJECTIVE: To investigate the effectiveness of dorsalis pedis flap series-parallel big toe nail composite tissue flap in the repairment of hand skin of degloving injury with tumb defect. METHODS: Between March 2009 and June 2013, 8 cases of hand degloving injury with thumb defect caused by machine twisting were treated. There were 7 males and 1 female with the mean age of 36 years (range, 26-48 years). Injury located at the left hand in 3 cases and at the right hand in 5 cases. The time from injury to hospitalization was 1.5-4.0 hours (mean, 2.5 hours). The defect area was 8 cm x 6 cm to 15 cm x 1 cm. The thumb defect was rated as degree I in 5 cases and as degree II in 3 cases. The contralateral dorsal skin flap (9 cm x 7 cm to 10 cm x 8 cm) combined with ipsilateral big toe nail composite tissue flap (2.5 cm x 1.8 cm to 3.0 cm x 2.0 cm) was used, including 3 parallel anastomosis flaps and 5 series anastomosis flaps. The donor site of the dorsal flap was repaired with thick skin grafts, the stumps wound was covered with tongue flap at the shank side of big toe. RESULTS: Vascular crisis occurred in 1 big toe nail composite tissue flap, margin necrosis occurred in 2 dorsalis pedis flap; the other flaps survived, and primary healing of wound was obtained. The grafted skin at dorsal donor site all survived, skin of hallux toe stump had no necrosis. Eight cases were followed up 4-20 months (mean, 15.5 months). All flaps had soft texture and satisfactory appearance; the cutaneous sensory recovery time was 4-7 months (mean, 5 months). At 4 months after operation, the two-point discrimination of the thumb pulp was 8-10 mm (mean, 9 mm), and the two-point discrimination of dorsal skin flap was 7-9 mm (mean, 8.5 mm). According to Society of Hand Surgery standard for the evaluation of upper part of the function, the results were excellent in 4 cases, good in 3 cases, and fair in 1 case. The donor foot had normal function. CONCLUSION: Dorsalis pedis flap series-parallel big toe nail composite tissue flap is an ideal way to repair hand skin defect, and reconstructs the thumb, which has many advantages, including simple surgical procedure, no limitation to recipient site, soft texture, satisfactory appearance and function of reconstructing thumb, and small donor foot loss.

Thinned chimeric radial collateral artery perforator flap in complex distal thumb reconstruction.

INTRODUCTION: Tissue loss accompanied by bone defects in the thumb is a challenging reconstruction problem. Traditional repair methods are unsatisfactory. METHODS: Microsurgical thumb reconstruction was performed using 13 thinned chimeric radial collateral artery (RCA) perforator flaps. The flap was created with a thinned skin paddle and humeral bone segments using independent perforators. Primary defatting was completed when the thickness of the perforator entry was approximately similar to that in the periphery. The posterior cutaneous nerve of the arm was carried to make a sensory flap. Defects were 8.5 × 4.5 cm(2) on average (ranging in size from 4.5 × 1.5 to 15.0 × 6.0 cm(2)), and flap size was 9.0 × 5.5 cm(2) on average (ranging in size from 5.0 × 2.0 to 16.0 × 7.0 cm(2)), whereas the humeral fragments were 2.0 × 1.0 cm(2) on average (ranging in size from 1.5 × 0.5 to 4.0 × 1.5 cm(2)). All data were expressed as mean ± SD. The cosmetic appearance of the donor and recipient sites, Kapandji opposition score and static two-point discrimination of the operated thumb were evaluated during a follow-up visit. RESULTS: Follow-up time was 16.6 months (ranging from 14 to 28 months). Flap thickness before defatting, measured immediately after flap elevation was 14.5 mm (ranging from 10.0 to 25.0 mm). Average flap thickness after defatting was 3.5 mm (ranging from 3.0 to 6.0 mm). Venous congestion occurred in two cases. Successful microsurgical revision was achieved in both cases. All flaps survived. Bone components achieved union in all cases at an average period of 4.8 months (ranging from 3 to 6 months). Based on Kapandji opposition score, the mean thumb opposition score was 6. The mean sensation of flap was 7.5 mm (ranging from 6 to 11 mm). No further flap revision or defatting procedures were required in all cases. Cosmetically acceptable results were achieved for all patients. CONCLUSIONS: Findings proved that thinned chimeric RCA perforator flap is a beneficial microsurgical alternative for reconstructing complex bone and soft tissue defects in thumb.