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Neurovascular Advancement Flap to Release Flexion Contracture of the Proximal Interphalangeal Joint
SURGICAL TECHNIQUE
Neurovascular Advancement Flap to Release Flexion Contracture of the Proximal Interphalangeal Joint James Tseng, MD,* Yu-Te Lin, MD* Various methods have been described to surgically release posttraumatic flexion contracture of the proximal interphalangeal joint. Extension of the distal digit often creates a soft tissue defect on the volar aspect of the finger. Although various flaps and skin grafting have been utilized for coverage of this defect, they can be associated with morbidity. We present our experience with a volar neurovascular advancement flap to achieve soft tissue release in proximal interphalangeal joint flexion contracture. This advancement flap is designed to include both digital neurovascular bundles and eliminates the need for a secondary procedure as it allows primary closure of the subsequent defect. It is indicated for contracture lengthening of 10 to 14 mm. Surgical considerations of flap design are discussed. (J Hand Surg Am. 2017;-(-):1.e1-e5. Copyright Ó 2017 by the American Society for Surgery of the Hand. All rights reserved.) Key words Flap, flexion contracture, neurovascular, PIP joint.
finger proximal interphalangeal (PIP) joint can affect hand function and thereby limit activities of daily living. Common reasons for flexion contracture of the PIP joints include (1) shortage or fibrosis of soft tissues, skin, subcutaneous tissue, flexor tendon sheath, collateral ligaments, and volar plate of the PIP joint, (2) adhesion of the flexor tendons, (3) contracture of flexor muscles, (4) osteoarthrosis of the PIP joint, or (5) any combination of these sequelae. When the articular joint is spared, correction of flexion contracture can be accomplished by releasing the affected soft tissues and
F
LEXION CONTRACTURE OF THE
From the *Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College, and Chang Gung University, Taipei, Taiwan. Received for publication July 27, 2016; accepted in revised form January 12, 2017. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Yu-Te Lin, MD, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, 222 Mai-Chin Road, Keelung City 204, Taiwan; e-mail: [email protected]. 0363-5023/17/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2017.01.007
tendons. We describe a neurovascular advancement flap derived from existing techniques for fingertip reconstruction and applied to flexion contracture release of the PIP joints. INDICATIONS Options for contracture release can vary depending on etiology. For contracted tendons, tenolysis and lengthening of the tendons are options or even sacrifice of the flexor digitorum sublimis can be considered. If the joint capsule is affected, capsulotomy with sequential release of the volar plate and accessory collateral ligaments release may be indicated. Compared with a palmar approach, a midlateral incision offers greater improvement in range of motion (ROM), attributed to its less traumatic nature and postoperative pain allowing for earlier and more intensive rehabilitation.1 A severe contracture or tissue loss can result in an open defect once the finger is fully extended. Local or distant flaps are usually required when the defect is not suitable for resurfacing with skin grafting. In order to avoid additional patient morbidity,
Ó 2017 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
1.e1
1.e2
DIGITAL NEUROVASCULAR ADVANCEMENT FLAP
this neurovascular advancement flap allows for flexion contracture release with primary closure of the wound.
Incisions are planned on the midlateral lines from the distal interphalangeal (DIP) crease to the MCP crease on one side and from the PIP to the MCP crease on the other side. Asymmetrical lateral incisions provide a wider pedicle base that helps to increase flap perfusion and to reduce venous congestion. To allow better exposure of the underlying soft tissue, an oblique incision can be extended from the midlateral incision at the DIP crease toward the pulp. The proximal incisions of the flap are designed on the palmar surface at the level of the MCP joint and are based on the standard V-Y advancement flap. Incision begins on the longer midlateral incision and is dissected dorsally to the neurovascular bundle by dividing the Cleland ligaments. Dissection then continues on the volar surface of the flexor tendon sheath toward the opposite neurovascular bundle. Care is taken to ensure both digital neurovascular bundles are included in the flap. All the soft tissue at the proximal V incision is divided, save the neurovascular bundles, which can be traced from their initial point of dissection and preserved. To expose the volar plate of the PIP joint, the flexor tendon sheath between the A2 and the A4 annular ligaments is opened, or resected if fibrosed. Tenolysis of adherent flexor tendons is done accordingly. The volar plate of the PIP joint is divided from its origin at the proximal phalanx. Accessory collateral ligaments and the corresponding flexor digitorum sublimis tendon are transected. The digit is then extended passively, and the flap is advanced and closed in a V-Y fashion at the proximal donor site. The dissection plane of this volar neurovascular advancement flap is similar to that of a Moberg flap used for fingertip reconstruction. This flap includes 2 midlateral incisions dissected volar to the flexor sheath, preserving the neurovascular bundles, and advanced on the palmar side for thumb tip reconstruction.2 Hueston3 later described the eponymous L-shaped lateral palmar advancement flap pedicled on a single neurovascular bundle for coverage following distal pulp amputation, with the transverse incision located over the MCP joint. Souquet4 later modified the Hueston flap to include both digital neurovascular bundles within the flap. Both flaps leave a triangular defect proximally at the transverse incision after advancement, necessitating secondary coverage, typically skin grafting. However, secondary scar contracture and vulnerability of the digital nerve should be considerations prior to grafting. By extending a V-shaped incision across the MCP palmar crease, any tension in the soft
CONTRAINDICATIONS Patients who require extension distance of 15 mm or more may not be appropriate candidates for this technique. Our experience shows that the flap can be advanced for approximately 10 to 14 mm without causing arterial insufficiency or nerve damage to the digit. Although we have achieved advancements of 15 and 20 mm in 2 patients with camptodactyly, these cases are atypical. In addition, the surgeon should be cognizant of the condition of the soft tissues on the volar aspect of the flap because significant scarring may also limit the distance of advancement. Previous injury to the digital arteries, although not an absolute contraindication, should be considered carefully along with any conditions that may cause ischemia to the flap. SURGICAL ANATOMY The PIP joint is a simple hinge joint bounded by periarticular soft tissue. Collateral ligaments originate from the proximal phalanx condyle and insert on the base of the middle phalanx. More proximal and volar are the origin of radial and ulnar accessory collateral ligaments (ACL). They attach to the volar plate, which in itself is anchored to the periosteum by checkrein ligaments and constitutes the base of the PIP joint. A thin capsule overlies the dorsal aspect of the joint, with some reinforcement provided by the central slip and lateral bands of the extensor mechanism. The joint is enveloped by flexor and extensor tendon sheaths and the transverse retinacular ligament that bridges them. The A3 annular ligament arises from the volar plate at the level of the PIP joint. The neurovascular bundles pass along each side of the joint within the Cleland and Grayson ligaments. SURGICAL TECHNIQUE Preoperative evaluation begins with eliciting the patient’s pertinent medical history regarding any conditions, injuries, or interventions to the involved finger. On examination, the length of the volar aspect of the contracted digit can be compared with the contralateral digit to determine the distance for advancement. Measurement is taken from the metacarpophalangeal (MCP) joint crease to the fingertip. Distances of 10 to 14 mm have readily been attained in our cohort of patients. The skin is also inspected for the availability of appropriate pliable soft tissue for use in the advancement flap. J Hand Surg Am.
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DIGITAL NEUROVASCULAR ADVANCEMENT FLAP
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FIGURE 1: A Straight angulated sides leave a shortage of tissue at the sides for defect coverage once the flap is advanced. B A gentle curvature of the sides allows not only more coverage but also better approximation of the incisions.
tissue here can be released. This is exemplified by the fact that advancement and closure of a Moberg flap may require flexion of the interphalangeal IP joint.5,6 To prevent flexion deformity of the interphalangeal joint, the Moberg flap was modified to extend the proximal flap with a V-shaped incision.6 Our volar neurovascular advancement flap is an amalgamation of these existing flaps, but applied to releasing flexion contractures of the PIP joint. Following flap advancement and PIP flexion contracture release, the proximal wound can be closed in a V-Y fashion. There are some technical aspects to consider in designing and harvesting this flap. The design of the proximal V of the flap should not contain strict angulated sides. When the flap is advanced, strict angulation leaves less skin to provide coverage of the defect (Fig. 1A). Instead, the shape of the flap should resemble a champagne flute glass. The gentle convexity of the curvature allows for more coverage at the base of the proximal phalanx. This shape also J Hand Surg Am.
improves approximation of the incision lines at the time of closure (Fig. 1B). In harvesting the flap, inclusion of both digital arteries helps to create a more reliable flap and to heal by primary intention. In situations in which the digital arteries may have been traumatized or revascularized previously, we advocate designing the shorter midlateral incision on the side of the digital artery unaffected by prior insult. This ensures that flap viability will not be affected should the injured artery ultimately be found unreliable or damaged during dissection. Similarly, perfusion of the distal pulp and dorsal finger will be less likely to be compromised should the midlateral incision need to be extended distal to the DIP crease. When there is no specific consideration of laterality of the major pedicle, our preference is to design the longer midlateral incision on the radial aspect of the thumb or index finger, but on the ulnar side for the little finger. Flap design for the middle and ring fingers can be based on surgeon preference. This provides better visualization during r
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DIGITAL NEUROVASCULAR ADVANCEMENT FLAP
FIGURE 2: Preoperative view of the left hand shows PIP joint flexion contracture of the middle and ring fingers.
FIGURE 3: Immediate postoperative view following incision closure. A neurovascular advancement flap was performed on the ring finger, whereas an arterialized venous flap was used for coverage after contracture release in the middle finger.
flap dissection to preserve neurovascular structures. Including both digital nerves, along with the dorsal branch, keeps sensory innervation intact. Using a longer midlateral incision allows for extensive dissection and facilitates tenolysis of the flexors and release of the PIP joint. It also enhances tension release and enables maximal flap advancement. Therefore, we suggest designing the longer midlateral incision on the side affected less by scarring. Dissection of the neurovascular bundle should commence outside of the injury zone to make the neurovascular structures less vulnerable to iatrogenic injury. Video A (available on the Journal’s web site at www.jhandsurg.org) demonstrates the operative procedure of the volar neurovascular advancement flap.
in the rehabilitation program. Patients are asked to wear their orthosis throughout the day except during their hourly ROM exercise sessions. During the remodeling phase, regular follow-up to monitor ROM prevents loss of progress already made in functional recovery. The orthosis can be limited to just nighttime use at this point. If there is major loss of skin elasticity, thermoplastic elastomer orthoses can be designed and molded to accentuate the pressure applied to the scar. The hand therapist routinely checks and refabricates these orthoses serially as necessary to ensure proper fit. Stretching the PIP joint and strengthening of intrinsic muscles are emphasized to improve passive and active ROM. Weekly hand therapy visits are arranged until scar maturation occurs, usually at the sixth postoperative month.
POSTOPERATIVE MANAGEMENT At our institution, rehabilitation includes intensive postoperative therapeutic exercises and orthoses application. The decision to use either intervention depends on the healing stage of the involved tissues. Pain and edema control are paramount during the initial inflammatory and proliferative phases of wound healing. A custom-fabricated orthosis is tailored to each patient’s hand to keep the MCP and PIP joints in maximal extension as soon as possible, typically within the first 3 postoperative days. Hand therapy visits that challenge the patient and orthosis adjustment are necessary to improve PIP joint ROM and deter adhesion formation. Whereas the goal of rehabilitation is to achieve as much functional recovery as possible, patients’ anxiety and fear of pain can be alleviated with careful monitoring of the intensity and frequency of the ROM exercises. Appropriate relief of pain and stiffness after exercise periods helps to encourage their ongoing participation J Hand Surg Am.
PEARLS AND PITFALLS Pearls 1. Champagne flute design of the proximal end of the flap is optimal. 2. Midlateral incisions can be tailored to patients’ history of prior trauma to aid dissection of the neurovascular structures in order to lessen potential iatrogenic injury. 3. Up to 15 mm of flap advancement can be achieved. 4. Robust blood supply allows flap to be performed reliably on previously operated fingers. 5. It allows resurfacing with glabrous skin that is characterized by stability, sensibility, and durability. Pitfalls 1. Inadequacy of flap coverage may result if the flap shape is designed too straight and angular. r
Vol. -, - 2017
DIGITAL NEUROVASCULAR ADVANCEMENT FLAP
2. Underestimating the distance of flap advancement may be a problem. 3. Poor placement of midlateral incisions limits proper dissection and visualization.
Case 2 A 33-year-old man presented with an industrial crush injury with incomplete amputation of the left index, middle, and ring fingers. Tendon repair and revascularization were performed. Flexion contracture of his middle and ring fingers developed as sequelae of his initial operation (Fig. 2). Subsequent surgical release of PIP joint contracture included tenolysis of flexors and release of the volar plate and ACL. The neurovascular advancement flap was performed on the ring finger with 12 mm of advancement achieved (Fig. 3). At 7.5 months’ follow-up, the postoperative ROM was 75 , representing a gain of 45 of PIP joint motion. The PIP joint of the middle finger was similarly released. However, owing to dense fibrotic scarring of the middle finger, an arterialized venous flap was transferred for a 2 3-cm2 defect after release. Video B (available on the Journal’s Web site at www.jhandsurg.org) shows postoperative ROM in this patient.
COMPLICATIONS 1. Neurovascular injury during dissection. 2. Overaggressive soft tissue release. 3. Flap failure. CASE EXAMPLES Case 1 A 55-year-old woman with a previous history of surgical intervention for stenosing tenosynovitis of multiple fingers presented 6 months after surgery with PIP joint contracture of the left thumb and ring finger. Preoperative evaluation of the ring finger demonstrated a 10-mm deficiency in extension when compared with the contralateral finger. This advancement distance, along with the presence of pliable soft tissue and no prior history of vascular compromise, made her an appropriate candidate for the volar neurovascular advancement flap. Intraoperative findings included scarring and contracture bands of the volar plate and ACL, which were released. The advancement flap was performed on the ringer finger as described, but multiple z-plasties were applied to the thumb at completion. With attentive follow-up and adherence to her rehabilitation, the patient’s ring finger PIP joint active ROM improved from 35 to 85 . Video A (available on the Journal’s Web site at www.jhandsurg.org) demonstrates the operative procedure of the volar neurovascular advancement flap in this patient.
J Hand Surg Am.
1.e5
REFERENCES 1. Brüser P, Poss T, Larkin G. Results of proximal interphalangeal joint release for flexion contractures: midlateral versus palmar incision. J Hand Surg Am. 1999;24(2):288e294. 2. Moberg E. Aspects of sensation in reconstructive surgery of the upper extremity. J Bone Joint Surg Am. 1964;46:817e825. 3. Hueston J. Local flap repair of fingertip injuries. Plast Reconstr Surg. 1966;37(4):349e350. 4. Souquet R. The asymmetric arterial advancement flap in distal pulp loss (modified Hueston’s flap [in English, French]. Ann Chir Main. 1985;4(3):233e238. 5. Chao JD, Huang JM, Wiedrich TA. Local hand flaps. J Am Soc Surg Hand. 2001;1(1):25e44. 6. Rehim SA, Chung KC. Local flaps of the hand. Hand Clin. 2014;30(2):137e151.
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Neurovascular Advancement Flap to Release Flexion Contracture of the Proximal Interphalangeal Joint James Tseng, MD,* Yu-Te Lin, MD* Various methods have been described to surgically release posttraumatic flexion contracture of the proximal interphalangeal joint. Extension of the distal digit often creates a soft tissue defect on the volar aspect of the finger. Although various flaps and skin grafting have been utilized for coverage of this defect, they can be associated with morbidity. We present our experience with a volar neurovascular advancement flap to achieve soft tissue release in proximal interphalangeal joint flexion contracture. This advancement flap is designed to include both digital neurovascular bundles and eliminates the need for a secondary procedure as it allows primary closure of the subsequent defect. It is indicated for contracture lengthening of 10 to 14 mm. Surgical considerations of flap design are discussed. (J Hand Surg Am. 2017;-(-):1.e1-e5. Copyright Ó 2017 by the American Society for Surgery of the Hand. All rights reserved.) Key words Flap, flexion contracture, neurovascular, PIP joint.
finger proximal interphalangeal (PIP) joint can affect hand function and thereby limit activities of daily living. Common reasons for flexion contracture of the PIP joints include (1) shortage or fibrosis of soft tissues, skin, subcutaneous tissue, flexor tendon sheath, collateral ligaments, and volar plate of the PIP joint, (2) adhesion of the flexor tendons, (3) contracture of flexor muscles, (4) osteoarthrosis of the PIP joint, or (5) any combination of these sequelae. When the articular joint is spared, correction of flexion contracture can be accomplished by releasing the affected soft tissues and
F
LEXION CONTRACTURE OF THE
From the *Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College, and Chang Gung University, Taipei, Taiwan. Received for publication July 27, 2016; accepted in revised form January 12, 2017. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Yu-Te Lin, MD, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, 222 Mai-Chin Road, Keelung City 204, Taiwan; e-mail: [email protected]. 0363-5023/17/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2017.01.007
tendons. We describe a neurovascular advancement flap derived from existing techniques for fingertip reconstruction and applied to flexion contracture release of the PIP joints. INDICATIONS Options for contracture release can vary depending on etiology. For contracted tendons, tenolysis and lengthening of the tendons are options or even sacrifice of the flexor digitorum sublimis can be considered. If the joint capsule is affected, capsulotomy with sequential release of the volar plate and accessory collateral ligaments release may be indicated. Compared with a palmar approach, a midlateral incision offers greater improvement in range of motion (ROM), attributed to its less traumatic nature and postoperative pain allowing for earlier and more intensive rehabilitation.1 A severe contracture or tissue loss can result in an open defect once the finger is fully extended. Local or distant flaps are usually required when the defect is not suitable for resurfacing with skin grafting. In order to avoid additional patient morbidity,
Ó 2017 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
1.e1
1.e2
DIGITAL NEUROVASCULAR ADVANCEMENT FLAP
this neurovascular advancement flap allows for flexion contracture release with primary closure of the wound.
Incisions are planned on the midlateral lines from the distal interphalangeal (DIP) crease to the MCP crease on one side and from the PIP to the MCP crease on the other side. Asymmetrical lateral incisions provide a wider pedicle base that helps to increase flap perfusion and to reduce venous congestion. To allow better exposure of the underlying soft tissue, an oblique incision can be extended from the midlateral incision at the DIP crease toward the pulp. The proximal incisions of the flap are designed on the palmar surface at the level of the MCP joint and are based on the standard V-Y advancement flap. Incision begins on the longer midlateral incision and is dissected dorsally to the neurovascular bundle by dividing the Cleland ligaments. Dissection then continues on the volar surface of the flexor tendon sheath toward the opposite neurovascular bundle. Care is taken to ensure both digital neurovascular bundles are included in the flap. All the soft tissue at the proximal V incision is divided, save the neurovascular bundles, which can be traced from their initial point of dissection and preserved. To expose the volar plate of the PIP joint, the flexor tendon sheath between the A2 and the A4 annular ligaments is opened, or resected if fibrosed. Tenolysis of adherent flexor tendons is done accordingly. The volar plate of the PIP joint is divided from its origin at the proximal phalanx. Accessory collateral ligaments and the corresponding flexor digitorum sublimis tendon are transected. The digit is then extended passively, and the flap is advanced and closed in a V-Y fashion at the proximal donor site. The dissection plane of this volar neurovascular advancement flap is similar to that of a Moberg flap used for fingertip reconstruction. This flap includes 2 midlateral incisions dissected volar to the flexor sheath, preserving the neurovascular bundles, and advanced on the palmar side for thumb tip reconstruction.2 Hueston3 later described the eponymous L-shaped lateral palmar advancement flap pedicled on a single neurovascular bundle for coverage following distal pulp amputation, with the transverse incision located over the MCP joint. Souquet4 later modified the Hueston flap to include both digital neurovascular bundles within the flap. Both flaps leave a triangular defect proximally at the transverse incision after advancement, necessitating secondary coverage, typically skin grafting. However, secondary scar contracture and vulnerability of the digital nerve should be considerations prior to grafting. By extending a V-shaped incision across the MCP palmar crease, any tension in the soft
CONTRAINDICATIONS Patients who require extension distance of 15 mm or more may not be appropriate candidates for this technique. Our experience shows that the flap can be advanced for approximately 10 to 14 mm without causing arterial insufficiency or nerve damage to the digit. Although we have achieved advancements of 15 and 20 mm in 2 patients with camptodactyly, these cases are atypical. In addition, the surgeon should be cognizant of the condition of the soft tissues on the volar aspect of the flap because significant scarring may also limit the distance of advancement. Previous injury to the digital arteries, although not an absolute contraindication, should be considered carefully along with any conditions that may cause ischemia to the flap. SURGICAL ANATOMY The PIP joint is a simple hinge joint bounded by periarticular soft tissue. Collateral ligaments originate from the proximal phalanx condyle and insert on the base of the middle phalanx. More proximal and volar are the origin of radial and ulnar accessory collateral ligaments (ACL). They attach to the volar plate, which in itself is anchored to the periosteum by checkrein ligaments and constitutes the base of the PIP joint. A thin capsule overlies the dorsal aspect of the joint, with some reinforcement provided by the central slip and lateral bands of the extensor mechanism. The joint is enveloped by flexor and extensor tendon sheaths and the transverse retinacular ligament that bridges them. The A3 annular ligament arises from the volar plate at the level of the PIP joint. The neurovascular bundles pass along each side of the joint within the Cleland and Grayson ligaments. SURGICAL TECHNIQUE Preoperative evaluation begins with eliciting the patient’s pertinent medical history regarding any conditions, injuries, or interventions to the involved finger. On examination, the length of the volar aspect of the contracted digit can be compared with the contralateral digit to determine the distance for advancement. Measurement is taken from the metacarpophalangeal (MCP) joint crease to the fingertip. Distances of 10 to 14 mm have readily been attained in our cohort of patients. The skin is also inspected for the availability of appropriate pliable soft tissue for use in the advancement flap. J Hand Surg Am.
r
Vol. -, - 2017
DIGITAL NEUROVASCULAR ADVANCEMENT FLAP
1.e3
FIGURE 1: A Straight angulated sides leave a shortage of tissue at the sides for defect coverage once the flap is advanced. B A gentle curvature of the sides allows not only more coverage but also better approximation of the incisions.
tissue here can be released. This is exemplified by the fact that advancement and closure of a Moberg flap may require flexion of the interphalangeal IP joint.5,6 To prevent flexion deformity of the interphalangeal joint, the Moberg flap was modified to extend the proximal flap with a V-shaped incision.6 Our volar neurovascular advancement flap is an amalgamation of these existing flaps, but applied to releasing flexion contractures of the PIP joint. Following flap advancement and PIP flexion contracture release, the proximal wound can be closed in a V-Y fashion. There are some technical aspects to consider in designing and harvesting this flap. The design of the proximal V of the flap should not contain strict angulated sides. When the flap is advanced, strict angulation leaves less skin to provide coverage of the defect (Fig. 1A). Instead, the shape of the flap should resemble a champagne flute glass. The gentle convexity of the curvature allows for more coverage at the base of the proximal phalanx. This shape also J Hand Surg Am.
improves approximation of the incision lines at the time of closure (Fig. 1B). In harvesting the flap, inclusion of both digital arteries helps to create a more reliable flap and to heal by primary intention. In situations in which the digital arteries may have been traumatized or revascularized previously, we advocate designing the shorter midlateral incision on the side of the digital artery unaffected by prior insult. This ensures that flap viability will not be affected should the injured artery ultimately be found unreliable or damaged during dissection. Similarly, perfusion of the distal pulp and dorsal finger will be less likely to be compromised should the midlateral incision need to be extended distal to the DIP crease. When there is no specific consideration of laterality of the major pedicle, our preference is to design the longer midlateral incision on the radial aspect of the thumb or index finger, but on the ulnar side for the little finger. Flap design for the middle and ring fingers can be based on surgeon preference. This provides better visualization during r
Vol. -, - 2017
1.e4
DIGITAL NEUROVASCULAR ADVANCEMENT FLAP
FIGURE 2: Preoperative view of the left hand shows PIP joint flexion contracture of the middle and ring fingers.
FIGURE 3: Immediate postoperative view following incision closure. A neurovascular advancement flap was performed on the ring finger, whereas an arterialized venous flap was used for coverage after contracture release in the middle finger.
flap dissection to preserve neurovascular structures. Including both digital nerves, along with the dorsal branch, keeps sensory innervation intact. Using a longer midlateral incision allows for extensive dissection and facilitates tenolysis of the flexors and release of the PIP joint. It also enhances tension release and enables maximal flap advancement. Therefore, we suggest designing the longer midlateral incision on the side affected less by scarring. Dissection of the neurovascular bundle should commence outside of the injury zone to make the neurovascular structures less vulnerable to iatrogenic injury. Video A (available on the Journal’s web site at www.jhandsurg.org) demonstrates the operative procedure of the volar neurovascular advancement flap.
in the rehabilitation program. Patients are asked to wear their orthosis throughout the day except during their hourly ROM exercise sessions. During the remodeling phase, regular follow-up to monitor ROM prevents loss of progress already made in functional recovery. The orthosis can be limited to just nighttime use at this point. If there is major loss of skin elasticity, thermoplastic elastomer orthoses can be designed and molded to accentuate the pressure applied to the scar. The hand therapist routinely checks and refabricates these orthoses serially as necessary to ensure proper fit. Stretching the PIP joint and strengthening of intrinsic muscles are emphasized to improve passive and active ROM. Weekly hand therapy visits are arranged until scar maturation occurs, usually at the sixth postoperative month.
POSTOPERATIVE MANAGEMENT At our institution, rehabilitation includes intensive postoperative therapeutic exercises and orthoses application. The decision to use either intervention depends on the healing stage of the involved tissues. Pain and edema control are paramount during the initial inflammatory and proliferative phases of wound healing. A custom-fabricated orthosis is tailored to each patient’s hand to keep the MCP and PIP joints in maximal extension as soon as possible, typically within the first 3 postoperative days. Hand therapy visits that challenge the patient and orthosis adjustment are necessary to improve PIP joint ROM and deter adhesion formation. Whereas the goal of rehabilitation is to achieve as much functional recovery as possible, patients’ anxiety and fear of pain can be alleviated with careful monitoring of the intensity and frequency of the ROM exercises. Appropriate relief of pain and stiffness after exercise periods helps to encourage their ongoing participation J Hand Surg Am.
PEARLS AND PITFALLS Pearls 1. Champagne flute design of the proximal end of the flap is optimal. 2. Midlateral incisions can be tailored to patients’ history of prior trauma to aid dissection of the neurovascular structures in order to lessen potential iatrogenic injury. 3. Up to 15 mm of flap advancement can be achieved. 4. Robust blood supply allows flap to be performed reliably on previously operated fingers. 5. It allows resurfacing with glabrous skin that is characterized by stability, sensibility, and durability. Pitfalls 1. Inadequacy of flap coverage may result if the flap shape is designed too straight and angular. r
Vol. -, - 2017
DIGITAL NEUROVASCULAR ADVANCEMENT FLAP
2. Underestimating the distance of flap advancement may be a problem. 3. Poor placement of midlateral incisions limits proper dissection and visualization.
Case 2 A 33-year-old man presented with an industrial crush injury with incomplete amputation of the left index, middle, and ring fingers. Tendon repair and revascularization were performed. Flexion contracture of his middle and ring fingers developed as sequelae of his initial operation (Fig. 2). Subsequent surgical release of PIP joint contracture included tenolysis of flexors and release of the volar plate and ACL. The neurovascular advancement flap was performed on the ring finger with 12 mm of advancement achieved (Fig. 3). At 7.5 months’ follow-up, the postoperative ROM was 75 , representing a gain of 45 of PIP joint motion. The PIP joint of the middle finger was similarly released. However, owing to dense fibrotic scarring of the middle finger, an arterialized venous flap was transferred for a 2 3-cm2 defect after release. Video B (available on the Journal’s Web site at www.jhandsurg.org) shows postoperative ROM in this patient.
COMPLICATIONS 1. Neurovascular injury during dissection. 2. Overaggressive soft tissue release. 3. Flap failure. CASE EXAMPLES Case 1 A 55-year-old woman with a previous history of surgical intervention for stenosing tenosynovitis of multiple fingers presented 6 months after surgery with PIP joint contracture of the left thumb and ring finger. Preoperative evaluation of the ring finger demonstrated a 10-mm deficiency in extension when compared with the contralateral finger. This advancement distance, along with the presence of pliable soft tissue and no prior history of vascular compromise, made her an appropriate candidate for the volar neurovascular advancement flap. Intraoperative findings included scarring and contracture bands of the volar plate and ACL, which were released. The advancement flap was performed on the ringer finger as described, but multiple z-plasties were applied to the thumb at completion. With attentive follow-up and adherence to her rehabilitation, the patient’s ring finger PIP joint active ROM improved from 35 to 85 . Video A (available on the Journal’s Web site at www.jhandsurg.org) demonstrates the operative procedure of the volar neurovascular advancement flap in this patient.
J Hand Surg Am.
1.e5
REFERENCES 1. Brüser P, Poss T, Larkin G. Results of proximal interphalangeal joint release for flexion contractures: midlateral versus palmar incision. J Hand Surg Am. 1999;24(2):288e294. 2. Moberg E. Aspects of sensation in reconstructive surgery of the upper extremity. J Bone Joint Surg Am. 1964;46:817e825. 3. Hueston J. Local flap repair of fingertip injuries. Plast Reconstr Surg. 1966;37(4):349e350. 4. Souquet R. The asymmetric arterial advancement flap in distal pulp loss (modified Hueston’s flap [in English, French]. Ann Chir Main. 1985;4(3):233e238. 5. Chao JD, Huang JM, Wiedrich TA. Local hand flaps. J Am Soc Surg Hand. 2001;1(1):25e44. 6. Rehim SA, Chung KC. Local flaps of the hand. Hand Clin. 2014;30(2):137e151.
r
Vol. -, - 2017