Objective To introduce the free multiple flaps of lowerextremity based on the anterior tibital vascular pedicle for primary repair of the complex burned hand deformities.Methods From September 2000 to February 2003, the lateral leg flap, dosalis pedis flap and trimmed first toe based on the anterior tibial vascular pedicle were utilized to reconstruct the thumb and repair the first web, thenar, wrist or palmar scar contracture simultaneously in 6 patients. The flap size of lateral leg and dosalis pedis ranged from 4 cm×10 cm to 7 cm×10 cm and from 5 cm×10 cm to 9 cm×12 cm, respectively.Resutls Six cases were treated and followed up for 6 weeks to 1 year. The transplanted flaps survived with satisfactory recovery in function and appearance of theburned hand. The function of donor lower extremity was not damaged. Conclusion The procedure of the free multiple flaps of lower extremity based on the anterior tibial vascular pedicle is reliable and effective for primaryrepair of burned hand.
ObjectiveTo study the causes and treatment of postoperative deviation secondary to thumb duplication resection. MethodsBetween February 2007 and June 2013,32 cases (33 thumbs) of postoperative deviation secondary to thumb duplication resection were treated,and the clinical data were retrospectively analyzed.There were 13 males and 19 females,aged 2-34 years (median,8 years).The left thumbs were involved in 7 cases,the right thumbs in 24 cases,and bilateral thumbs in 1 case.Of 33 thumbs,2 were rated as type Ⅱ,4 as type Ⅲ,10 as type IV,7 as type V,and 10 as type VⅡ according to Wassel classification.The average time between duplicated thumb resection and admission was 6.5 years (range,1-29 years).Nine thumbs only had ulnar deviation of the metacarpophalangeal (MP) joint;8 thumbs only had radial deviation of the interphalangeal (IP) joint;10 thumbs only had ulnar deviation of the IP joint;and 6 thumbs had ulnar deviation of the MP joint combined with radial deviation of the IP joint.The mean deviation degree of the MP joint was 32.3°(range,20-40°),and the mean deviation degree of the IP joint was 42.5°(range,30-110°).Operation methods were chosen specially according to the deformity,including remnant bone or cartilage resection,restoring normal alignment,and soft tissue balance. ResultsAll wounds got first stage healing and there was no complication associated with operation.Postoperative follow-up period ranged from 6 to 70 months (mean,34 months).The skeleton alignment of the thumbs was improved on the X-ray images;all osteotomy got union at 5-10 weeks (mean,6 weeks).Deviation was completely corrected in 31 thumbs;the preoperative deviation degree was too large to correct completely in 2 thumbs with a postoperative deviation degree of 10°.The motion degree was similar to that at preoperation in 13 thumbs;the motion degree decreased in 20 thumbs,which did not affect the function of the thumbs.Nineteen cases (20 thumbs) were followed more than 2 years,there was no recurrence of deviation and all thumbs developed well,but the size of affected thumb was smaller than that of the contralateral side in 14 cases (14 thumbs). ConclusionGetting good result and preventing postoperative deviation for thumb duplication resection acquires appropriate preoperative design,reconstruction of the insertion of the abductor pollicis brevis,transposition of the flexor and extensor pollicis longus insertion,and essential osteotomy play important roles in preventing postoperative deviation after thumb duplication resection.Individualized treatment plan for deviation should be made according to the degree and the cause of deviation.
Objective To evaluate the function of the reconstructed thumbs and the donor feet after thumb reconstructions with modified wrap-around flap. Methods A total of 65 patients who accepted thumb reconstruction with the modified wrap-around flap between January 2003 and October 2007 were followed up, including 54 males and 11 females with an average age of 33 years (range 15-46 years). There were 12 cases of skin degloving injury and late class I B defect, 44 cases of class II defect and 9 cases of class III A defect. The reconstructed thumbs and donor feet were examined andevaluated. Foot function index-verbal rating scales (FFI-5pt), American Orthopaedic Foot and Ankle Society (AOFAS) forhallux metatarsophalangeal-interphalangeal score, gait analysis and dynamic pedobarography were conducted to 20 patients who were followed up recently. Results Sixty-five patients were followed up 6-60 months with an average of 22 months. The reconstructed thumbs had aesthetic appearance and satisfactory range of motion. The two-point discrimination was (9.7 ± 2.8) mm, showing statistically significant difference (P lt; 0.05) when compared with that of the contralateral normal thumb [(4.2 ± 1.1) mm]. Full or most length of the donor toes were preserved in 63 patients. The width of remaining plantar strip skin that covered the plantar weight-bearing area was (24.5 ± 3.7) mm, and its two-point discrimination was (9.0 ± 2.6) mm; showing no statistically significant difference (P gt; 0.05) when compared with that of contralateral normal one [(8.1 ± 1.9) mm]. Of the 20 patients who were followed up recently, the evaluation of the FFI-5pt score showed that the pain scale score was 5.6 ± 4.5, the disabil ity scale score was 1.2 ± 2.7, and the FFI-5pt total scale score was 3.2 ± 2.9. The results of AOFAS cl inical rating scale showed that the pain scale score was 34.0 ± 5.0, the function scale score was 38.7 ± 4.2, the al igment scale score was 15.0 ± 0, and the total AOFAS scale score was 87.7 ± 7.4. There was no statistically significant difference (P gt; 0.05) in the durations of subphases of the gait cycle between the donor foot and the contralateral normal foot, and in the peak force and force-time integral of the two whole foot. The peak force of the donor toe was significantly smaller than that of the contralateral normal toe (P lt; 0.05), but there was no significant difference in the peak pressure (P gt; 0.05); and there were no significant differences in the peak forcesand peak pressures of other six anatomical sites of the two feet (P gt; 0.05). Conclusion Using the modified wrap-around flap for thumb reconstruction, aesthetic and functional thumbs can be obtained, and most of the function of the donor feet can be preserved.
Objective To study the improved index finger dorsal island flap for primary repair of thumb tip injury. Methods Between January 2009 and February 2010, 23 patients with thumb tip injury were treated. There were 17 males and 6 females, aged 21-47 years (mean, 27.5 years). The causes of injury were mechanical injury in 18 cases and heavy crushing injury in 5 cases. The time from injury to operation was 2.5-5.0 hours (mean, 3.5 hours). The defect locations included ulnar palmar defect in 5 cases, dorsal foot defect in 6 cases, radial palmar defect in 8 cases, and radial dorsal defect in 4 cases. All patients complicated by exposure of the thumb distal phalanx. The wound area varied from 2.1 cm × 1.8 cm to 2.8 cm × 2.5 cm. According to distal soft tissue defect of thumb, a modified index finger dorsal island flap was designed, key point of which was moved forward, and defects were repaired with the flaps. The size of flap was 2.3 cm × 2.0 cm to 3.0 cm × 2.7 cm. The donor sites were repaired with skin graft. Results All the flaps and grafts survived after operation and the wounds healed by first intention. All patients were followed up 6-12 months with an average of 6.4 months. The appearance and texture of the flaps were excellent. At last follow-up, the sensation of the flaps recovered to S3+ in 18 cases, to S3 in 2 cases, and to S2 in 3 cases. The two-point discrimination was 3-4 mm. Thumb opposition function was normal without contracture at the first web space. The skin graft at the donor site survived completely, and the metacarpophalangeal joint at donor site had the flexion and extension function. Conclusion Using a modified index finger dorsal island flap for primary repair thumb tip injury is a simple operation, which has good blood supply and high survival rate. When the pedicle flap rotation point is moved forward 10 mm or more, it can meet the needs of repairing thumb tip defect.
Objective To introduce the surgical procedure and indication of the dorsoulnar arterial retrograde flap of the thumb in repair of soft tissue defect. Methods From March 2000 to March 2001, 12 cases of soft tissue defect with exposed bone at the distal thumb were involved. Ten flaps were pedicled distally at the proximal rotation point, 25 cm proximal to the cuticule. Two flaps were pedicled distally at the distal rotation point, 1.0 cm proximal to the cuticule. The flaps harvested in this study were 1.1 cm×1.3 cm to 1.8 cm×2.5 cm.Results All the flaps survived. After an follow-up of 2 to 14 months postoperatively, the appearance of the thumbs were satisfactory, except those of 2 thumbs repaired by the flaps transferred at the distal rotation point, which were bulkiness because of theuncovered pedicle. In 6 cases, the defect of finger pulp was repaired, and the 2point discrimination was measured 810 mm. The same range of motion of the thumb IP joint were observed in both sides in all cases.Conclusion The optimal indication of the procedure is soft tissue defect at the distal thumb.
ObjectiveTo investigate the effectiveness of free second toe dorsal flap combined with middle or ring finger island flap for repairing degloved thumbs. MethodsBetween August 2009 and June 2013, 6 patients with degloving injury of the thumb were treated using free second toe dorsal flap combined with middle or ring finger island flap. There were 4 males and 2 females, aged 19-44 years (mean, 32 years). The left thumb was involved in 2 cases and the right thumb in 4 cases, including 5 cases of type II and 1 case of type III degloving injury. The size of wound was 5.5 cm×2.5 cm to 6.5 cm×5.0 cm. After emergency debridemented, 5 patients underwent vacuum sealing drainage and surgical repair after 3-5 days; 1 patient underwent abdominal embedding and repair after 14 days. The size of second toe dorsal flap ranged from 2.5 cm×2.2 cm to 4.2 cm×3.0 cm, and the size of middle or ring finger island flap ranged from 2.0 cm×1.5 cm to 3.5 cm×2.8 cm. Neurorrhaphy was performed between the plantar digital nerve of the second toe and the proper digital nerve at the recipient site in 5 cases, and no nerve anastomose in 1 case. All the distal phalanxes were partially excised. The donor sites were covered with free skin grafts. ResultsAll of the flaps survived completely and incision healed by first intention. Three patients had alloesthesia of the middle or ring finger island flaps. All of the 6 patients were followed up from 6 months to 3 years (mean, 23 months). The flaps had good color and soft texture, and the finger had satisfactory appearance, but the fingernails were smaller than that of normal side. The sensation of the dorsum of the second toe reached S3, and the mean two-point discrimination of the pulp was 6 mm (range, 4-7 mm). According to total active movement (TAM) system, the function of the thumbs was excellent in 5 cases and good in 1 case. ConclusionA combination of free second toe dorsal flap and middle or ring finger island flap is a useful and reliable technique for reconstruction of a degloved thumb.
Objective To explore the effect of the first dorsal metacarpal artery-based pedicle dictyo-pattern sublobe flaps in repairing irregular wounds on thumbs and index fingers. Methods From December 2006 to March 2009, 15 patients with irregular wounds on thumbs and index fingers were treated, including 11 males and 4 femals, with an average age of 31 years (range, 18-48 years). Of them, 6 cases of hyperplastic scar of postburn had a 2-25 years course of disease (7.5 years onaverage) and 9 cases of machine injury had a 14-30 days course of disease (20 days on average). In 8 thumb wounds on palmaris, there were 3 cases of rhomboid wounds, 1 case of C-shape wound, and 4 cases of irregular wounds; the area of wounds ranged from 4.5 cm × 3.0 cm to 5.5 cm × 4.5 cm and wounds were treated by the first dorsal metacarpal artery-based proximate pedicle dictyo-pattern sublobe flaps (5 cm × 3 cm to 6 cm × 5 cm). In 7 index fingers wounds on dorsi-fingers, there were 3 cases of 2-wounds, 4 cases of irregular wounds; the area of wounds ranged from 1.0 cm × 0.5 cm to 2.2 cm × 2.0 cm and wounds were treated by the first dorsal metacarpal artery-based distal pedicle dictyo-pattern sublobe flaps (1.2 cm × 0.5 cm to 3.0 cm × 2.2 cm). The donor sites were covered with skin grafts or sutured directly. Results All of the flaps survived completely, the wound of recipient site healed at stage I. The free skin graft on donor site survived completely, the wound of donor site healed at stage I. All cases were followed up for 6-12 months (9 months on average). There was good appearance of flaps. The two point discrimination was 5-7 mm for the proximate pedicle flaps and 9-10 mm for the distal pedicle flaps. The thumbs had digital opposition, opposition function, the index fingers had no dysfunction. According to Hand Surgery Association Society of Chinese Medical Association Society standard for the part function evaluation trial-use of upper l imb, the results of the total active movement were excellent in 14 cases, and good in 1 case. The l ine-scar was existed at donor site of the case of direct suture, the function of thumb web had no dysfunction. Conclusion The first dorsal metacarpal artery-based pedicle dictyo-pattern sublobe flaps can repair the irregular wounds on thumbs and index fingers. It has rel iable blood supply and simple operation.
It is difficult to repair the pulp defect of finger with good function. Here reported two cases of pulp defect of the thumb which were repaired with free palmris brevis musculo-cutaneous flap. The flap was designed as the following: taken the line crossing the pisiform and metacarpo-phalangeal joint of the little finger as the longitudinal axis of the flap. The proximal end of the flap was at the level of pisiform and the distal end was the distal transverse palmar crease. The radial border was the radial side of the palmris brevis and ulnar border was the ulnar edge of the palm. The flap should not be larger than 6.5 cm x 2.5 cm. The flap was dissected with proper ulnar vessels and the accompanying arterial branch and superficial branch of the ulnar nerve. The flap was transferred to repair the pulp defect of the thumb. The vessels were anastomosed with the radial artery and cephalic vein at the snuffbox. The nerves were sutured to the digital nerve. Three months after operation, the defect was healed and the sensation of pulp was recovered. The donor area was painless and without sensation disturbance. The motion of the little finger was normal. The function of the thumb was restored. It was concluded that the palmaris brevis musculocutaneous flap is one of the best donor region to repair pulp defect of thumb.
ObjectiveTo investigate the effectiveness of double osteotomy and lengthening of proximal phalanx and metacarpal with Ilizarov technique in treatment of thumb defect. MethodsBetween February 2017 and June 2019, 6 patients with traumatic thumb defects were treated with double osteotomy and lengthening of proximal phalanx and metacarpal by Ilizarov technique. There were 5 males and 1 female. The age ranged from 28 to 57 years, with an average of 41.5 years. There were 3 cases on the left side and 3 cases on the right side. All patients were admitted to the hospital in emergency department after injury, and the stump of the thumb was trimmed and sutured. The osteotomy plane was the distal part of the proximal phalanx in 4 cases and the interphalangeal joint in 2 cases. The interval between injury and osteotomy was 20-245 days (median, 34.5 days). After minimally invasive osteotomy and placement of a semi-circular external fixator, the lengthening began on the 5th day. The proximal phalanx and metacarpal were lengthened by 0.5 mm every day, once every 12 hours. The thumb of the affected side was distracted to the middle of the distal phalanx of the healthy thumb, and the fixator was removed after the bone healed. ResultsThe distraction time was 14-23 days, with an average of 18.8 days. The osteotomies were healed with healing time of 91-147 days (mean, 120.2 days). The total distraction length of the proximal phalanx and metacarpal was 1.40-2.25 cm, with an average of 1.86 cm; healing index was 51.0-72.2 days/cm, with an average of 64.9 days/cm. All patients were followed up 5-12 months (mean, 8.2 months). At last follow-up, the two-point discrimination was 5.3-8.5 mm with an average of 6.98 mm. According to the evaluation standard of the upper limb part of the Chinese Medical Association, the score was 10-14, with an average of 12.5. Among them, 4 cases were excellent and 2 cases were good, with an excellent and good rate of 100%. All patients were satisfied with the function and appearance of thumb after operation. The Quick Disabilities of Arm, Shoulder, and Hand (Quick-DASH) score was 2.3-9.1, with an average of 6.1. ConclusionThe double osteotomy and lengthening of proximal phalanx and metacarpal with Ilizarov technique is an effective method for the treatment of thumb defects.
Objective To evaluate the results of thumb opposition function by transferring the extensor carpi ulnaris and the extensor poll icis brevis muscle tendons. Methods Between March 2006 and August 2009, 35 patients with dysfunction of thumb opposition were treated and the thumb opposition function was reconstruced by transferring the extensor carpi ulnaris and the extensor poll icis brevis muscle tendons. There were 25 males and 10 females with an average age of 33.5 years (range, 20-53 years); 20 had median nerve injury in the wrist and 15 had median nerve injury with ulnar nerve injury. The causes were sharp instrument injury in 24 cases, blunt injury in 9 cases, and hot crush injury in 2 cases. Six cases complicated by shaft fractures of radius and ulna. All the patients underwent an operation of nerve repair at 1 to 3 hours after injury (mean, 2 hours). The time from injury to reconstructing operation was 6-14 months (mean, 7.5 months). Two cases was able to abduct thumb sl ightly, the others had no functions of thumb abduct and thumb opposition. Results All the wounds gained the primary healing. The patients were followed up 12-18 months (mean, 14 months). The wrist joint angle and thumb dorsal extension were satisfactory. Thumb abduct and thumb opposition function returned to normal in 20 patients with simple median nerve injury; in 15 patients with median nerve injury and ulnar nerve injury, thumb abduct and thumb opposition function returned to normal in 15 and 13, respectively. According to ZHAO Shuqiang’s standard, the results of thumb opposition function were normal in all patients at 12 months after operation. Conclusion It is a convenient and efficient procedure to reconstruct thumb opposition function by transferring the extensor carpi ulnaris and the extensor poll icis brevis muscle tendons.