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Reconstruction of multiple fingertip injuries with reverse flow homodigital flap
Injury, Int. J. Care Injured 45 (2014) 1569–1573
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Reconstruction of multiple fingertip injuries with reverse flow homodigital flap Mehmet A. Acar a, Yunus Gu¨zel b,*, Ali Gu¨lec¸ a, Faik Tu¨rkmen c, ¨ mer F. Erkoc¸ak a, Gu¨ney Yılmaz a O a b c
Selc¸uk University, Selc¸uk School of Medicine, Department of Orthopaedics and Traumatology, Campus of Alaeddin Keykubat, Selc¸uklu 42075, Konya, Turkey Ordu University, School of Medicine, Department of Orthopaedics and Traumatology, Campus of Cumhuriyet, Ordu 52200, Turkey Necmettin Erbakan University, Meram School of Medicine, Department of Orthopaedics and Traumatology, Campus of Meram, Meram 42080, Konya, Turkey
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 8 June 2014
Aim: Hand trauma may lead to multiple fingertip defects, causing functional restrictions. We evaluated the use of reverse-flow homodigital flap reconstruction of the distal phalanx and pulp defects associated with multiple finger injuries. Methods: We retrospectively evaluated 11 male patients who presented at our emergency department (January 2011–March 2013) with multiple fingertip injuries and who were treated with a reverse-flow homodigital flap. Evaluations included age, sex, defect size, flap survival rate, complications, cold intolerance, two-point discrimination, range of motion (ROM), quick disabilities of the arm, shoulder, and hand (DASH) score, and return to work time. Results: Completely, 22 reverse-flow homodigital flaps were applied to at least two fingertip injuries at the distal phalanx. Ten flaps survived postoperatively. The exception was partial flap loss on one finger. The mean follow-up was 14.2 months. At the final follow-up, the mean static two-point discrimination value was 10.3 mm. Mean ROMs of interphalangeal joints were 65.318 (distal) and 105.778 (proximal). Donor sites were covered with full-thickness skin grafts from the wrist or antecubital area. There were no complications related to the donor site and no development of cold intolerance in any finger. The mean quick DASH score was 4.12. All patients returned to work in an average of 8.3 weeks. Conclusions: The reconstruction of multiple fingertip injuries with reverse-flow homodigital flaps is a safe, effective method that can be combined with other local finger flaps. These flaps can be applied to two consecutive fingers without reducing finger length or function. ß 2014 Elsevier Ltd. All rights reserved.
Keywords: Distal injuries Homodigital flaps Island flaps Multiple finger defects
Introduction Traumatic soft-tissue defects seen with multiple fingertip injuries can cause functional loss. When the tendon, bone, or nail bed is exposed, the reconstruction of extensive distal phalanx defects is important to preserve finger function. The aim of fingertip reconstruction is to preserve functional length and sensitivity, maintain joint flexibility, prevent the development of joint stiffness or neuroma, minimize aesthetic deformities, and provide a quick return to work [1,2]. It is also important that the damage to the donor site is acceptable and that there is no cold intolerance. Various treatment options are available depending on the level and geometry of the injury, including anterior triangular
* Corresponding author. Tel.: +90 5056996368. E-mail address: [email protected] (Y. Gu¨zel). http://dx.doi.org/10.1016/j.injury.2014.06.009 0020–1383/ß 2014 Elsevier Ltd. All rights reserved.
flaps (Atasoy/V–Y flap), cross-finger flaps, thenar flaps, abdominal flaps, reverse radial forearm flap, homodigital–heterodigital flaps, and revision amputations [1–4]. For reconstruction of multiple finger defects, wide flaps are generally taken from the abdomen [5]. The disadvantages of this method are the delayed sensory recovery, patient discomfort, and the need for a second operation. Additional procedures are required for contouring. Thus, the application of local flaps (V–Y advancement flaps, cross finger flaps, thenar flaps, and homodigital flaps) is preferred as they avoid these problems. After Lai et al. [6] and Kojima et al. [7] introduced homodigital pedicle flaps, this treatment option gained popularity for fingertip injuries. Although homodigital island flaps have been used for two decades, they are generally used to treat single finger injuries. Very limited literature described the use of the homodigital flaps in multiple finger injuries [8,9]. We believed that homodigital flaps would be functional and increase patient comfort when used for
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multiple fingertip defects similar to the single fingertip defects. The aim of this study was to evaluate the results of reconstructions using reverse-flow homodigital flaps to treat patients with multiple finger distal phalanx and pulp defects. Materials and methods The study included 11 male patients who presented at the Emergency Department of Selcuk University Medical Faculty Hospital (Konya, Turkey) with composite defects at the level of the distal phalanges in multiple fingers. They underwent reconstruction using reverse-flow homodigital flaps between January 2011 and March 2013. The local ethics committee approved the study. Patients with multiple fingertip soft-tissue defects (involving bone, tendon, and/or nerve tissue) >1 cm2 who were unable to be managed by V–Y advancement flap and who intended to maintain the length of their digits were included in the study. Patients with multiple finger injuries who were managed with a combination of homodigital reverse flow flap and other local flaps were excluded from the study. The same surgeon (M.A.A.) performed all of the operations. Follow-up data were obtained from hospital charts with a minimum 6 months of follow-up. As all the patients had two fingertip defects, these injuries were reconstructed with double homodigital reverse-flow flaps. We recorded the ages of the patients at presentation, their sex, defect localization, rate of postoperative flap survival, and any complications. At the end of a mean 14-month follow-up period, the patients were evaluated for cold intolerance, two-point discrimination, joint ROM, quick disabilities of the arm, shoulder, and hand (DASH) score [10], and the time it took to return to work. Sensory recovery in the flaps was evaluated using the American Hand Surgery Association two-point discrimination test, in which the discrimination points and measurements are classified as excellent (<6 mm), good (6–10 mm), fair (11–15 mm), or poor (>15 mm) [11,12]. The aesthetic satisfaction of the patients was evaluated subjectively using a five-point Likert scale (poor, satisfactory, fair, good, and excellent) [13]. The ROM values of the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints of the affected fingers were measured using a goniometer to assess extension restrictions at the level of the proximal and distal phalanx. Cold intolerance was evaluated using a cold intolerance pain scale questionnaire [14]. Descriptive values for the patient were expressed as means and standard deviations. Statistical analyses were performed with SPSS for Windows software (version 21.00; SPSS, Chicago, IL, USA). Surgical technique The circulation of the hand was evaluated preoperatively in all patients using the Allen test.
All operations were performed under axillary block anaesthesia and a tourniquet. As routine prophylaxis, second generation cephalosporin was administered intravenously. The flap was designed depending on the defect size. The radial part of the thumb’s contact sides was preserved in all patients. Flaps were harvested from the ulnar part of each finger. The flap was selected central to the mid-lateral line. A mid-lateral longitudinal or zigzag incision approach was taken with each finger. The neurovascular pedicle was ligated proximally to the flap, the flap was freed, and the perivascular soft tissue was preserved for better venous drainage. After raising the neurovascular island flap and rotating it 1808 over the pedicle, it was adapted to the defect area. After adaptation was complete, the digital nerve was transferred along with the flap and anastomosed to the terminal end of the digital nerve at the injury site or to the contralateral digital nerve. The same procedure was then applied to the other finger being reconstructed, after which the tourniquet was opened and the flap circulation assessed. Donor site coverage was achieved with fullthickness skin grafts taken from the volar aspect of the wrist or the antecubital region in all patients. After the operation, a short arm splint was used for 1 week to allow stabilization of the flaps and skin graft. Active and passive finger mobilization exercises were started at the end of the first week. Results Reconstruction of fingertip injuries was performed in 11 male patients using 22 homodigital reverse flow flaps. The patient’s mean age was 31.1 years (range 18–43 years). Overall, 72.7% of the injuries were due to industrial accidents and the rest to avulsion injuries. Each patient in the study had more than one finger injury. The incidences of right and left hand injuries were 36.4% and 63.6%, respectively. The numbers of concomitantly affected digits were as follows: 4 (18.4%) index fingers, 11 (50.0%) middle fingers, and 7 (31.8%) ring fingers (Table 1). All but one of the flaps healed completely with full flap survival. The exception was a flap that became partially necrotic Primer flap survival rate was 95.45%. The mean follow-up was 14.09 months (range 7–24 months). The mean static two-point discrimination value was 10.3 mm. According to the classification of the American Hand Surgery Association for two-point discrimination measurements, the discrimination was evaluated as good in 18 fingers and fair in 4. The mean range of motion (ROM) values were 65.318 for the DIP joints and 105.778 for the PIP joints. The mean cold intolerance scores were 1.81/4.54. The mean quick DASH score was 4.12 (range 0–9.09) (Table 2). The survival of the 22 reverse-flow homodigital flaps was assessed during the follow-up period. One finger developed partial necrosis following venous congestion, but recovered after de-
Table 1 Demographic data for the patients, injury type, and defect size. Case
Gender
Age (year)
Mechanisms of injury
Injured fingers
Defect size (cm)
Injuries to the nailbed
1 2 3 4 5 6 7 8 9 10 11
M M M M M M M M M M M
18 23 42 22 40 30 31 37 27 29 43
Industrial Industrial Avulsion Avulsion Industrial Industrial Industrial Avulsion Industrial Industrial Industrial
R III/IV L III/IV R II/III L II/III R III/IV L III/IV L II/III R III/IV L III/IV L II/III L III/IV
2.4 2.0/2.0 2.1 2.6 2.1/2.5 2.2 2.4 2.0/2.2 2.0 2.4 1.8/2.4 1.8 2.6 2.0/2.4 2.1 2.2 2.0/2.0 2.0 2.4 2.1/2.0 2.1 2.6 2.0/2.4 2.2 2.4 1.8/2.0 1.8 2.2 2.0/2.0 1.8 2.4 1.7/2.0 2.1
++ ++ ++ ++ / / ++ ++ ++ ++ ++
Mean
31.09
accident accident
accident accident accident accident accident accident
2.3/1.8
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Table 2 Follow-up periods, complications, and results for all of the patients. Case
Follow-up period (months)
Flap survival
1 2
11 18
+/+ +/+
3 4 5
12 24 18
+/+ +/+ +/
6 7 8 9 10 11
7 8 12 17 9 19
+/+ +/+ +/+ +/+ +/+ +/+
Mean
14.18
Complications
Nail deformity in the 4th finger
Partial flap necrosis in the 4th finger
Flexion contracture in the both fingers + nail deformity in the 4th finger
Cold intolerance scores
ROM (DIF/PIF) (8)
2-point discrimination
Quick DASH scores
Likert aesthetic satisfaction scale
0/0 10/0
90/110; 90/100 60/100;60/100
10.6/10.3 12.1/9.6
0 2.27
Excellent Excellent
8 8
0/10 0/0 0/20
72/110; 60/110 90/108; 88/90 58/110; 70/108
8.8/10.7 11.3/10.1 9.6/11.7
2.27 0 9.09
Excellent Excellent Good
8 8 10
10/10 0/0 0/0 0/10 0/0 0/0
90/110; 90/105 90/105; 90/100 60/110; 88/110 0/110; 0/108 46/110; 90/95 55/110; 0/108
9.9/10.2 8.7/10.5 10.6/10.7 10.1/9.8 10.3/11.4 9.2/10.0
4.54 4.54 4.54 6.81 4.54 6.81
Excellent Excellent Excellent Excellent Excellent Excellent
8 6 6 7 8 15
1.81/4.54
64.63/108.45; 66/10.309
10.10/10.45
4.12
bridement of the necrotic tissue. In the same patient, a flapthinning operation was performed 6 months after the first surgery because the patient complained of swelling in the pulp of the third finger (case 5). Nail deformity along with nail bed impairment developed in one patient (case 2). In another patient, flexion contracture developed in both of the operated fingers. At 11 weeks after the first operation, the contracture was loosened with multiple Z-plasties (Fig. 1a–c). Nail deformity without clinical discomfort developed in the fourth finger in the same patient (case 11) (Fig. 1d). The donor sites were closed in all patients with a full-thickness skin graft. None of the patients developed donor-site complications
Time to return to work (weeks)
8.36
or cold intolerance. According to the five-point Likert scale, aesthetic satisfaction was rated as good by one patient and excellent by all of the rest. All patients returned to work within a mean of 8.3 weeks. Discussion The aim of the study was to examine the surgical technique, results, and complications of the reverse-flow homodigital flap method applied to multiple fingertip injuries. At the end of a mean 14-month follow-up, the results of homodigital flaps applied to 22 fingers were evaluated for donor-site complications, cold intolerance, sensory recovery, joint ROM, quick DASH scores, and time to
Fig. 1. Case 11 (a) Defect in the distal interphalangeal area of fingers 3 and 4 and the prepared homodigital flaps. (b) At postoperative week 11, contractures opened with multiple Z-plasties. (c) Dorsolateral image at 11 weeks shows full extension of the interphalangeal joints following Z-plasty on the fingers. (d) Full flexion of the interphalangeal joints and nail deformity in the fourth finger.
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return to work. Among 22 reverse-flow homodigital flaps performed, during the follow-up period, only one finger exhibited a complication with partial flap loss. Primary flap survival was observed in 21 fingers. Multiple fingertip defects caused by hand injuries create a serious problem for both surgeons and patients. V–Y flaps are often used for single-finger defects. Thenar or cross-finger flaps or dorsal metacarpal artery flaps are used to treat multiple fingertip defects. The desired results, however, have not been obtained [1,15]. Hence, for multiple finger injuries, consecutive operations with single flaps or wide flaps obtained from the abdomen and shaped for their intended locations are generally preferred [16]. This is only true for large defects. These methods do have disadvantages, such as the need for repeated operations, a long period of immobilization, and the fact that the harvested tissue is thicker than hand tissue. The use of pedicular homodigital flaps as local flap alternatives in fingertip reconstruction was first described by Lai et al. [6] and subsequently by Kojima et al. [7]. In 2001, Kim et al. reported the use of homodigital island flaps for reconstructing defects at the mid and distal phalanx levels of 25 fingers in 23 patients. The results were determined to be both functionally and aesthetically successful [17]. Similarly, we have obtained successful results using homodigital flaps for multiple finger injuries of 22 fingers in 11 patients. In the literature, reports have indicated that various flaps have been used to reconstruct multiple finger injuries. Multiple cross finger flaps are the most common treatment for multiple fingertip defects. Xie et al. [18] used free dorsalis pedis flaps to treat multiple finger injuries in two patients. At the end of the 10- and 12-month follow-up periods, respectively, the two patients had recovered without any problems. Du et al. treated multiple finger injuries in 30 patients with random abdominal single-pedicled, three-leaved flaps. After a mean 12.6-month follow-up, all the flaps had survived and all patients indicated satisfactory functional and aesthetic results [19]. In a study similar to the current one, Momeni et al. used 11 reverse-flow homodigital island flaps to reconstruct single-finger tendon, bone, or joint defects with accompanying distal phalanx defects in 11 patients. In the retrospective analysis, venous congestion and partial flap necrosis were observed in one patient. The mean two-point discrimination measurement was 9 mm in that case. None of the patients reported cold intolerance, and all were able to return to work within 4.5 weeks – results similar to those of the current study [20]. Kaleli et al. used five reverse-flow homodigital flaps for finger defects. Three of the patients had tissue defects at the fingertip [8]. In these cases, digital nerve anastomosis with the counter-lateral digital nerve made the flaps sensitive. In two patients, the tissue defect was on the dorsum of the middle phalanx level. In these cases, the flaps were nonsensitive. Fingersensitive function was satisfactory in fingertip applications. Han et al. also reconstructed 120 fingers with reverse-flow homodigital flaps after fingertip injury. Flap loss was not observed in any patients in their study. Neurorrhaphy was performed to improve sensibility in 21 patients. Although the two-point discrimination was 6.1 mm in sensate flaps, it was 10.2 mm in nonsensate counterparts in 41 patients who were followed up >6 months [21]. In the current study, the two-point discrimination values were similar to those reported in the literature. The time taken to return to work of the patients in the current study was longer than that reported in other studies. This is thought possibly to be due to the types of injury in the current study and may be associated with accompanying nail bed damage. In another study by Chen et al., reconstruction with dorsal homodigital island flaps was applied to 30 fingers in 12 patients with multiple finger defects. Although 26 fingers were observed to have flap survival with no problems, flap necrosis was reported in 4
fingers. The authors concluded that dorsal homodigital island flaps can be used as a less-invasive and easily applied technique for multiple finger injuries [9]. Both distal and proximal homodigital island flaps have advantages in the reconstruction of fingertips (e.g., providing the possibility of single-stage surgery and limiting surgery to only the finger with the defect). In addition, as the skin of the lateral surface of the proximal phalanx is hairless and thick, it is similar to the thickness of the volar pulp, which is another reason for preferring reconstruction. In the current study, by using flaps taken from the same area rather than free or distant flaps, the flaps were easier to apply. Moreover, with the donor site in the same area, it was possible to perform these operations with regional anaesthesia. Single-stage surgery and relatively short operating times were other advantages. However, it must be kept in mind that with this method the flap size is restricted and the flap has the potential risk of venous insufficiency. The need to sacrifice a digital artery is another disadvantage. Because of the disadvantages that arise from the sacrifice of a neurovascular bundle, pedicle flaps, which are supplied by a dorsal branch of the digital artery, have been used. The anastomosis network between the volar and dorsal sides of the hand supplies these reverse-flow flaps. It has been stated in the literature that these flaps, by using the dorsal side of the finger skin, can be used for fingertip reconstruction without having to sacrifice a digital artery. However, the aforementioned flaps are usually not enough to cover a large defect. The risk of developing venous insufficiency and the need for nerve coaptation when used as a sensate flap are other drawbacks of these flaps [22,23]. This study has some limitations in that it was retrospective, there was no control group, and the number of patients was relatively low. Other weak points were that the cases did not have standard injuries, and the accompanying bone, tendon, and nerve tissue injuries could not be standardized. In addition, there were differences in the hand skills, occupations, and capabilities of the individuals. Thus, very different times were required to return to daily activities or work. Similar case series in the literature presented no model of standard injury or gold-standard treatment modality. With these complex hand injuries, the lack of a gold standard treatment method shows that there are several points that still require research. Therefore, the clinical results of different surgical methods applied to hand injuries will continue to contribute to the research and literature. Conclusion The managements of multiple fingertip injuries with reverseflow homodigital flaps can be an alternative to other pedicle flaps in appropriate patients, particularly for those in whom local advancement flaps are insufficient and protection of finger length and function is expected. All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008 [5]. Informed consent was obtained from all patients for being included in the study. conflict of interest The authors declare that there are no conflict of interests. References [1] Lore´a P, Chahidi N, Marchesi S, Ezzedine R, Marin Braun F, Dury M. Reconstruction of fingertip defects with the neuro vascular tranquilli-leali flap. J Hand Surg [Br] 2006;31(3):280–4.
M.A. Acar et al. / Injury, Int. J. Care Injured 45 (2014) 1569–1573 [2] Melone Jr CP, Beasley RW, Carstens Jr JH. The thenar flap: an analysis of its use in 150 cases. J Hand Surg [Am] 1982;7:291–7. [3] Lemmon JA, Janis JE, Rohrich RJ. Soft-tissue injuries of the fingertip: methods of evaluation and treatment: an algorithmic approach. Plast Reconstr Surg 2008;122:105e–17e. [4] Karacaoglu E, Gokce A. Perforator-based reverse radial forearm flap to reconstruct multiple third-degree burn defects of the fingers. J Burn Care Res 2008;29(2):398–402. [5] Senarath-Yapa K, Bell DR. ‘Front and back’ flaps for multiple dorsal and palmar digital skin loss. J Hand Surg Eur 2010;35:721–4. [6] Lai CS, Lin SD, Yang CC. The reverse digital artery island flap for fingertip reconstruction. Ann Plast Surg 1989;22:495–500. [7] Kojima T, Tsuchida Y, Hirase´ Y, Endo T. Reverse vascular pedicle digital island flap. Br J Plast Surg 1990;43:290–5. [8] Kaleli T, Ersozlu S, Ozturk C. Double reverse-flow island flaps for two adjacent finger tissue defect. Arch Orthop Trauma Surg 2004;124(3):157–60. [9] Chen C, Tang P, Zhang L, et al. Repair of multiple finger defects using the dorsal homodigital island flaps. Injury 2013;44:1582–8. [10] Beaton DE, Wright JG, Katz JN. Development of the QuickDASH: comparison of the three item-reduction approaches. J Bone Joint Surg Am 2005;87: 1038–46. [11] Crosby PM, Dellon AL. Comparison of two-point discrimination testing devices. Microsurgery 1989;10:134–7. [12] Dellon AL, Kallman CH. Evaluation of functional sensation in the hand. J Hand Surg [Am] 1983;8:865–70. [13] Allen IE, Seaman CA. Likert scales and data analyses. Quality Prog 2007;40(7): 64–5.
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[14] Irwin MS, Gilbert SE, Terenghi G, Smith RW, Green CJ. Cold intolerance following peripheral nerve injury: natural history and factors predicting severity of symptoms. J Hand Surg [Br] 1997;22:308–16. [15] Iwasawa M, Ohtsuka Y, Kushima H, et al. Arterialised venous flaps from the thenar and hypothenar regions for repairing finger pulp tissue losses. Plast Reconstr Surg 1997;99:1765–70. [16] Borschel GH. A three-subunit latissimus dorsi muscle free flap for single-stage coverage of the hand and three adjacent fingers. Hand 2010;5:99–101. [17] Kim KS, Yoo SI, Kim DY, Lee SY, Cho BH. Fingertip reconstruction using a volar flap based on the transverse palmar branch of the digital artery. Ann Plast Surg 2001;47:263–8. [18] Xie G, Hu Z, Miao C, et al. The free triple chimeric dorsalis pedis flaps for repair of multifingersoft tissue defects:a report oftwo cases. Microsurgery 2013;33:660–6. [19] Du ZG, Xiu XL, Wang W, et al. Abdominal random single pedicled flap of three leaves for the treatment of multiple finger skin defects. Zhongguo Gu Shang 2012;25:579–81 [in Chinese]. [20] Momeni A, Zajonc H, Kalash Z, Stark GB, Bannasch H. Reconstruction of distal phalangeal injuries 326 with the reverse homodigital island flap. Injury 2008;39:1460–3. [21] Han SK, Lee BI, Kim WK. The reverse digital artery island flap: clinical experience in 120 fingers. Plast Reconstr Surg 1998;101:1006–11. [22] Shao X, Chen C, Zhang X, Yu Y, Ren D, Lu L. Coverage of fingertip defect using a dorsal island pedicle 330 flap including both dorsal digital nerves. J Hand Surg [Am] 2009;34:1474–81. [23] Chen C, Tang P, Zhang X. The dorsal homodigital island flap based on the dorsal branch of the digital artery: a review of 166 cases. Plast Reconstr Surg 2014;133:519e–29e.
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Reconstruction of multiple fingertip injuries with reverse flow homodigital flap Mehmet A. Acar a, Yunus Gu¨zel b,*, Ali Gu¨lec¸ a, Faik Tu¨rkmen c, ¨ mer F. Erkoc¸ak a, Gu¨ney Yılmaz a O a b c
Selc¸uk University, Selc¸uk School of Medicine, Department of Orthopaedics and Traumatology, Campus of Alaeddin Keykubat, Selc¸uklu 42075, Konya, Turkey Ordu University, School of Medicine, Department of Orthopaedics and Traumatology, Campus of Cumhuriyet, Ordu 52200, Turkey Necmettin Erbakan University, Meram School of Medicine, Department of Orthopaedics and Traumatology, Campus of Meram, Meram 42080, Konya, Turkey
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 8 June 2014
Aim: Hand trauma may lead to multiple fingertip defects, causing functional restrictions. We evaluated the use of reverse-flow homodigital flap reconstruction of the distal phalanx and pulp defects associated with multiple finger injuries. Methods: We retrospectively evaluated 11 male patients who presented at our emergency department (January 2011–March 2013) with multiple fingertip injuries and who were treated with a reverse-flow homodigital flap. Evaluations included age, sex, defect size, flap survival rate, complications, cold intolerance, two-point discrimination, range of motion (ROM), quick disabilities of the arm, shoulder, and hand (DASH) score, and return to work time. Results: Completely, 22 reverse-flow homodigital flaps were applied to at least two fingertip injuries at the distal phalanx. Ten flaps survived postoperatively. The exception was partial flap loss on one finger. The mean follow-up was 14.2 months. At the final follow-up, the mean static two-point discrimination value was 10.3 mm. Mean ROMs of interphalangeal joints were 65.318 (distal) and 105.778 (proximal). Donor sites were covered with full-thickness skin grafts from the wrist or antecubital area. There were no complications related to the donor site and no development of cold intolerance in any finger. The mean quick DASH score was 4.12. All patients returned to work in an average of 8.3 weeks. Conclusions: The reconstruction of multiple fingertip injuries with reverse-flow homodigital flaps is a safe, effective method that can be combined with other local finger flaps. These flaps can be applied to two consecutive fingers without reducing finger length or function. ß 2014 Elsevier Ltd. All rights reserved.
Keywords: Distal injuries Homodigital flaps Island flaps Multiple finger defects
Introduction Traumatic soft-tissue defects seen with multiple fingertip injuries can cause functional loss. When the tendon, bone, or nail bed is exposed, the reconstruction of extensive distal phalanx defects is important to preserve finger function. The aim of fingertip reconstruction is to preserve functional length and sensitivity, maintain joint flexibility, prevent the development of joint stiffness or neuroma, minimize aesthetic deformities, and provide a quick return to work [1,2]. It is also important that the damage to the donor site is acceptable and that there is no cold intolerance. Various treatment options are available depending on the level and geometry of the injury, including anterior triangular
* Corresponding author. Tel.: +90 5056996368. E-mail address: [email protected] (Y. Gu¨zel). http://dx.doi.org/10.1016/j.injury.2014.06.009 0020–1383/ß 2014 Elsevier Ltd. All rights reserved.
flaps (Atasoy/V–Y flap), cross-finger flaps, thenar flaps, abdominal flaps, reverse radial forearm flap, homodigital–heterodigital flaps, and revision amputations [1–4]. For reconstruction of multiple finger defects, wide flaps are generally taken from the abdomen [5]. The disadvantages of this method are the delayed sensory recovery, patient discomfort, and the need for a second operation. Additional procedures are required for contouring. Thus, the application of local flaps (V–Y advancement flaps, cross finger flaps, thenar flaps, and homodigital flaps) is preferred as they avoid these problems. After Lai et al. [6] and Kojima et al. [7] introduced homodigital pedicle flaps, this treatment option gained popularity for fingertip injuries. Although homodigital island flaps have been used for two decades, they are generally used to treat single finger injuries. Very limited literature described the use of the homodigital flaps in multiple finger injuries [8,9]. We believed that homodigital flaps would be functional and increase patient comfort when used for
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multiple fingertip defects similar to the single fingertip defects. The aim of this study was to evaluate the results of reconstructions using reverse-flow homodigital flaps to treat patients with multiple finger distal phalanx and pulp defects. Materials and methods The study included 11 male patients who presented at the Emergency Department of Selcuk University Medical Faculty Hospital (Konya, Turkey) with composite defects at the level of the distal phalanges in multiple fingers. They underwent reconstruction using reverse-flow homodigital flaps between January 2011 and March 2013. The local ethics committee approved the study. Patients with multiple fingertip soft-tissue defects (involving bone, tendon, and/or nerve tissue) >1 cm2 who were unable to be managed by V–Y advancement flap and who intended to maintain the length of their digits were included in the study. Patients with multiple finger injuries who were managed with a combination of homodigital reverse flow flap and other local flaps were excluded from the study. The same surgeon (M.A.A.) performed all of the operations. Follow-up data were obtained from hospital charts with a minimum 6 months of follow-up. As all the patients had two fingertip defects, these injuries were reconstructed with double homodigital reverse-flow flaps. We recorded the ages of the patients at presentation, their sex, defect localization, rate of postoperative flap survival, and any complications. At the end of a mean 14-month follow-up period, the patients were evaluated for cold intolerance, two-point discrimination, joint ROM, quick disabilities of the arm, shoulder, and hand (DASH) score [10], and the time it took to return to work. Sensory recovery in the flaps was evaluated using the American Hand Surgery Association two-point discrimination test, in which the discrimination points and measurements are classified as excellent (<6 mm), good (6–10 mm), fair (11–15 mm), or poor (>15 mm) [11,12]. The aesthetic satisfaction of the patients was evaluated subjectively using a five-point Likert scale (poor, satisfactory, fair, good, and excellent) [13]. The ROM values of the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints of the affected fingers were measured using a goniometer to assess extension restrictions at the level of the proximal and distal phalanx. Cold intolerance was evaluated using a cold intolerance pain scale questionnaire [14]. Descriptive values for the patient were expressed as means and standard deviations. Statistical analyses were performed with SPSS for Windows software (version 21.00; SPSS, Chicago, IL, USA). Surgical technique The circulation of the hand was evaluated preoperatively in all patients using the Allen test.
All operations were performed under axillary block anaesthesia and a tourniquet. As routine prophylaxis, second generation cephalosporin was administered intravenously. The flap was designed depending on the defect size. The radial part of the thumb’s contact sides was preserved in all patients. Flaps were harvested from the ulnar part of each finger. The flap was selected central to the mid-lateral line. A mid-lateral longitudinal or zigzag incision approach was taken with each finger. The neurovascular pedicle was ligated proximally to the flap, the flap was freed, and the perivascular soft tissue was preserved for better venous drainage. After raising the neurovascular island flap and rotating it 1808 over the pedicle, it was adapted to the defect area. After adaptation was complete, the digital nerve was transferred along with the flap and anastomosed to the terminal end of the digital nerve at the injury site or to the contralateral digital nerve. The same procedure was then applied to the other finger being reconstructed, after which the tourniquet was opened and the flap circulation assessed. Donor site coverage was achieved with fullthickness skin grafts taken from the volar aspect of the wrist or the antecubital region in all patients. After the operation, a short arm splint was used for 1 week to allow stabilization of the flaps and skin graft. Active and passive finger mobilization exercises were started at the end of the first week. Results Reconstruction of fingertip injuries was performed in 11 male patients using 22 homodigital reverse flow flaps. The patient’s mean age was 31.1 years (range 18–43 years). Overall, 72.7% of the injuries were due to industrial accidents and the rest to avulsion injuries. Each patient in the study had more than one finger injury. The incidences of right and left hand injuries were 36.4% and 63.6%, respectively. The numbers of concomitantly affected digits were as follows: 4 (18.4%) index fingers, 11 (50.0%) middle fingers, and 7 (31.8%) ring fingers (Table 1). All but one of the flaps healed completely with full flap survival. The exception was a flap that became partially necrotic Primer flap survival rate was 95.45%. The mean follow-up was 14.09 months (range 7–24 months). The mean static two-point discrimination value was 10.3 mm. According to the classification of the American Hand Surgery Association for two-point discrimination measurements, the discrimination was evaluated as good in 18 fingers and fair in 4. The mean range of motion (ROM) values were 65.318 for the DIP joints and 105.778 for the PIP joints. The mean cold intolerance scores were 1.81/4.54. The mean quick DASH score was 4.12 (range 0–9.09) (Table 2). The survival of the 22 reverse-flow homodigital flaps was assessed during the follow-up period. One finger developed partial necrosis following venous congestion, but recovered after de-
Table 1 Demographic data for the patients, injury type, and defect size. Case
Gender
Age (year)
Mechanisms of injury
Injured fingers
Defect size (cm)
Injuries to the nailbed
1 2 3 4 5 6 7 8 9 10 11
M M M M M M M M M M M
18 23 42 22 40 30 31 37 27 29 43
Industrial Industrial Avulsion Avulsion Industrial Industrial Industrial Avulsion Industrial Industrial Industrial
R III/IV L III/IV R II/III L II/III R III/IV L III/IV L II/III R III/IV L III/IV L II/III L III/IV
2.4 2.0/2.0 2.1 2.6 2.1/2.5 2.2 2.4 2.0/2.2 2.0 2.4 1.8/2.4 1.8 2.6 2.0/2.4 2.1 2.2 2.0/2.0 2.0 2.4 2.1/2.0 2.1 2.6 2.0/2.4 2.2 2.4 1.8/2.0 1.8 2.2 2.0/2.0 1.8 2.4 1.7/2.0 2.1
++ ++ ++ ++ / / ++ ++ ++ ++ ++
Mean
31.09
accident accident
accident accident accident accident accident accident
2.3/1.8
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Table 2 Follow-up periods, complications, and results for all of the patients. Case
Follow-up period (months)
Flap survival
1 2
11 18
+/+ +/+
3 4 5
12 24 18
+/+ +/+ +/
6 7 8 9 10 11
7 8 12 17 9 19
+/+ +/+ +/+ +/+ +/+ +/+
Mean
14.18
Complications
Nail deformity in the 4th finger
Partial flap necrosis in the 4th finger
Flexion contracture in the both fingers + nail deformity in the 4th finger
Cold intolerance scores
ROM (DIF/PIF) (8)
2-point discrimination
Quick DASH scores
Likert aesthetic satisfaction scale
0/0 10/0
90/110; 90/100 60/100;60/100
10.6/10.3 12.1/9.6
0 2.27
Excellent Excellent
8 8
0/10 0/0 0/20
72/110; 60/110 90/108; 88/90 58/110; 70/108
8.8/10.7 11.3/10.1 9.6/11.7
2.27 0 9.09
Excellent Excellent Good
8 8 10
10/10 0/0 0/0 0/10 0/0 0/0
90/110; 90/105 90/105; 90/100 60/110; 88/110 0/110; 0/108 46/110; 90/95 55/110; 0/108
9.9/10.2 8.7/10.5 10.6/10.7 10.1/9.8 10.3/11.4 9.2/10.0
4.54 4.54 4.54 6.81 4.54 6.81
Excellent Excellent Excellent Excellent Excellent Excellent
8 6 6 7 8 15
1.81/4.54
64.63/108.45; 66/10.309
10.10/10.45
4.12
bridement of the necrotic tissue. In the same patient, a flapthinning operation was performed 6 months after the first surgery because the patient complained of swelling in the pulp of the third finger (case 5). Nail deformity along with nail bed impairment developed in one patient (case 2). In another patient, flexion contracture developed in both of the operated fingers. At 11 weeks after the first operation, the contracture was loosened with multiple Z-plasties (Fig. 1a–c). Nail deformity without clinical discomfort developed in the fourth finger in the same patient (case 11) (Fig. 1d). The donor sites were closed in all patients with a full-thickness skin graft. None of the patients developed donor-site complications
Time to return to work (weeks)
8.36
or cold intolerance. According to the five-point Likert scale, aesthetic satisfaction was rated as good by one patient and excellent by all of the rest. All patients returned to work within a mean of 8.3 weeks. Discussion The aim of the study was to examine the surgical technique, results, and complications of the reverse-flow homodigital flap method applied to multiple fingertip injuries. At the end of a mean 14-month follow-up, the results of homodigital flaps applied to 22 fingers were evaluated for donor-site complications, cold intolerance, sensory recovery, joint ROM, quick DASH scores, and time to
Fig. 1. Case 11 (a) Defect in the distal interphalangeal area of fingers 3 and 4 and the prepared homodigital flaps. (b) At postoperative week 11, contractures opened with multiple Z-plasties. (c) Dorsolateral image at 11 weeks shows full extension of the interphalangeal joints following Z-plasty on the fingers. (d) Full flexion of the interphalangeal joints and nail deformity in the fourth finger.
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return to work. Among 22 reverse-flow homodigital flaps performed, during the follow-up period, only one finger exhibited a complication with partial flap loss. Primary flap survival was observed in 21 fingers. Multiple fingertip defects caused by hand injuries create a serious problem for both surgeons and patients. V–Y flaps are often used for single-finger defects. Thenar or cross-finger flaps or dorsal metacarpal artery flaps are used to treat multiple fingertip defects. The desired results, however, have not been obtained [1,15]. Hence, for multiple finger injuries, consecutive operations with single flaps or wide flaps obtained from the abdomen and shaped for their intended locations are generally preferred [16]. This is only true for large defects. These methods do have disadvantages, such as the need for repeated operations, a long period of immobilization, and the fact that the harvested tissue is thicker than hand tissue. The use of pedicular homodigital flaps as local flap alternatives in fingertip reconstruction was first described by Lai et al. [6] and subsequently by Kojima et al. [7]. In 2001, Kim et al. reported the use of homodigital island flaps for reconstructing defects at the mid and distal phalanx levels of 25 fingers in 23 patients. The results were determined to be both functionally and aesthetically successful [17]. Similarly, we have obtained successful results using homodigital flaps for multiple finger injuries of 22 fingers in 11 patients. In the literature, reports have indicated that various flaps have been used to reconstruct multiple finger injuries. Multiple cross finger flaps are the most common treatment for multiple fingertip defects. Xie et al. [18] used free dorsalis pedis flaps to treat multiple finger injuries in two patients. At the end of the 10- and 12-month follow-up periods, respectively, the two patients had recovered without any problems. Du et al. treated multiple finger injuries in 30 patients with random abdominal single-pedicled, three-leaved flaps. After a mean 12.6-month follow-up, all the flaps had survived and all patients indicated satisfactory functional and aesthetic results [19]. In a study similar to the current one, Momeni et al. used 11 reverse-flow homodigital island flaps to reconstruct single-finger tendon, bone, or joint defects with accompanying distal phalanx defects in 11 patients. In the retrospective analysis, venous congestion and partial flap necrosis were observed in one patient. The mean two-point discrimination measurement was 9 mm in that case. None of the patients reported cold intolerance, and all were able to return to work within 4.5 weeks – results similar to those of the current study [20]. Kaleli et al. used five reverse-flow homodigital flaps for finger defects. Three of the patients had tissue defects at the fingertip [8]. In these cases, digital nerve anastomosis with the counter-lateral digital nerve made the flaps sensitive. In two patients, the tissue defect was on the dorsum of the middle phalanx level. In these cases, the flaps were nonsensitive. Fingersensitive function was satisfactory in fingertip applications. Han et al. also reconstructed 120 fingers with reverse-flow homodigital flaps after fingertip injury. Flap loss was not observed in any patients in their study. Neurorrhaphy was performed to improve sensibility in 21 patients. Although the two-point discrimination was 6.1 mm in sensate flaps, it was 10.2 mm in nonsensate counterparts in 41 patients who were followed up >6 months [21]. In the current study, the two-point discrimination values were similar to those reported in the literature. The time taken to return to work of the patients in the current study was longer than that reported in other studies. This is thought possibly to be due to the types of injury in the current study and may be associated with accompanying nail bed damage. In another study by Chen et al., reconstruction with dorsal homodigital island flaps was applied to 30 fingers in 12 patients with multiple finger defects. Although 26 fingers were observed to have flap survival with no problems, flap necrosis was reported in 4
fingers. The authors concluded that dorsal homodigital island flaps can be used as a less-invasive and easily applied technique for multiple finger injuries [9]. Both distal and proximal homodigital island flaps have advantages in the reconstruction of fingertips (e.g., providing the possibility of single-stage surgery and limiting surgery to only the finger with the defect). In addition, as the skin of the lateral surface of the proximal phalanx is hairless and thick, it is similar to the thickness of the volar pulp, which is another reason for preferring reconstruction. In the current study, by using flaps taken from the same area rather than free or distant flaps, the flaps were easier to apply. Moreover, with the donor site in the same area, it was possible to perform these operations with regional anaesthesia. Single-stage surgery and relatively short operating times were other advantages. However, it must be kept in mind that with this method the flap size is restricted and the flap has the potential risk of venous insufficiency. The need to sacrifice a digital artery is another disadvantage. Because of the disadvantages that arise from the sacrifice of a neurovascular bundle, pedicle flaps, which are supplied by a dorsal branch of the digital artery, have been used. The anastomosis network between the volar and dorsal sides of the hand supplies these reverse-flow flaps. It has been stated in the literature that these flaps, by using the dorsal side of the finger skin, can be used for fingertip reconstruction without having to sacrifice a digital artery. However, the aforementioned flaps are usually not enough to cover a large defect. The risk of developing venous insufficiency and the need for nerve coaptation when used as a sensate flap are other drawbacks of these flaps [22,23]. This study has some limitations in that it was retrospective, there was no control group, and the number of patients was relatively low. Other weak points were that the cases did not have standard injuries, and the accompanying bone, tendon, and nerve tissue injuries could not be standardized. In addition, there were differences in the hand skills, occupations, and capabilities of the individuals. Thus, very different times were required to return to daily activities or work. Similar case series in the literature presented no model of standard injury or gold-standard treatment modality. With these complex hand injuries, the lack of a gold standard treatment method shows that there are several points that still require research. Therefore, the clinical results of different surgical methods applied to hand injuries will continue to contribute to the research and literature. Conclusion The managements of multiple fingertip injuries with reverseflow homodigital flaps can be an alternative to other pedicle flaps in appropriate patients, particularly for those in whom local advancement flaps are insufficient and protection of finger length and function is expected. All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008 [5]. Informed consent was obtained from all patients for being included in the study. conflict of interest The authors declare that there are no conflict of interests. References [1] Lore´a P, Chahidi N, Marchesi S, Ezzedine R, Marin Braun F, Dury M. Reconstruction of fingertip defects with the neuro vascular tranquilli-leali flap. J Hand Surg [Br] 2006;31(3):280–4.
M.A. Acar et al. / Injury, Int. J. Care Injured 45 (2014) 1569–1573 [2] Melone Jr CP, Beasley RW, Carstens Jr JH. The thenar flap: an analysis of its use in 150 cases. J Hand Surg [Am] 1982;7:291–7. [3] Lemmon JA, Janis JE, Rohrich RJ. Soft-tissue injuries of the fingertip: methods of evaluation and treatment: an algorithmic approach. Plast Reconstr Surg 2008;122:105e–17e. [4] Karacaoglu E, Gokce A. Perforator-based reverse radial forearm flap to reconstruct multiple third-degree burn defects of the fingers. J Burn Care Res 2008;29(2):398–402. [5] Senarath-Yapa K, Bell DR. ‘Front and back’ flaps for multiple dorsal and palmar digital skin loss. J Hand Surg Eur 2010;35:721–4. [6] Lai CS, Lin SD, Yang CC. The reverse digital artery island flap for fingertip reconstruction. Ann Plast Surg 1989;22:495–500. [7] Kojima T, Tsuchida Y, Hirase´ Y, Endo T. Reverse vascular pedicle digital island flap. Br J Plast Surg 1990;43:290–5. [8] Kaleli T, Ersozlu S, Ozturk C. Double reverse-flow island flaps for two adjacent finger tissue defect. Arch Orthop Trauma Surg 2004;124(3):157–60. [9] Chen C, Tang P, Zhang L, et al. Repair of multiple finger defects using the dorsal homodigital island flaps. Injury 2013;44:1582–8. [10] Beaton DE, Wright JG, Katz JN. Development of the QuickDASH: comparison of the three item-reduction approaches. J Bone Joint Surg Am 2005;87: 1038–46. [11] Crosby PM, Dellon AL. Comparison of two-point discrimination testing devices. Microsurgery 1989;10:134–7. [12] Dellon AL, Kallman CH. Evaluation of functional sensation in the hand. J Hand Surg [Am] 1983;8:865–70. [13] Allen IE, Seaman CA. Likert scales and data analyses. Quality Prog 2007;40(7): 64–5.
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[14] Irwin MS, Gilbert SE, Terenghi G, Smith RW, Green CJ. Cold intolerance following peripheral nerve injury: natural history and factors predicting severity of symptoms. J Hand Surg [Br] 1997;22:308–16. [15] Iwasawa M, Ohtsuka Y, Kushima H, et al. Arterialised venous flaps from the thenar and hypothenar regions for repairing finger pulp tissue losses. Plast Reconstr Surg 1997;99:1765–70. [16] Borschel GH. A three-subunit latissimus dorsi muscle free flap for single-stage coverage of the hand and three adjacent fingers. Hand 2010;5:99–101. [17] Kim KS, Yoo SI, Kim DY, Lee SY, Cho BH. Fingertip reconstruction using a volar flap based on the transverse palmar branch of the digital artery. Ann Plast Surg 2001;47:263–8. [18] Xie G, Hu Z, Miao C, et al. The free triple chimeric dorsalis pedis flaps for repair of multifingersoft tissue defects:a report oftwo cases. Microsurgery 2013;33:660–6. [19] Du ZG, Xiu XL, Wang W, et al. Abdominal random single pedicled flap of three leaves for the treatment of multiple finger skin defects. Zhongguo Gu Shang 2012;25:579–81 [in Chinese]. [20] Momeni A, Zajonc H, Kalash Z, Stark GB, Bannasch H. Reconstruction of distal phalangeal injuries 326 with the reverse homodigital island flap. Injury 2008;39:1460–3. [21] Han SK, Lee BI, Kim WK. The reverse digital artery island flap: clinical experience in 120 fingers. Plast Reconstr Surg 1998;101:1006–11. [22] Shao X, Chen C, Zhang X, Yu Y, Ren D, Lu L. Coverage of fingertip defect using a dorsal island pedicle 330 flap including both dorsal digital nerves. J Hand Surg [Am] 2009;34:1474–81. [23] Chen C, Tang P, Zhang X. The dorsal homodigital island flap based on the dorsal branch of the digital artery: a review of 166 cases. Plast Reconstr Surg 2014;133:519e–29e.