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This report describes the successful use of a free sensory medial plantar flap for the reconstruction of the volar skin of the index finger. Six months after the operation a corrective procedure was performed because the flap was bulky. A favourable result was obtained both functionally and aesthetically, with two-point discrimination of 4 mm, one year after reconstruction.
The authors present the anatomy and clinical applications of a new donor site for free or pedicled transfers. It is localised on the posterior aspect of the forearm, over the distal radius, and based on a posterior branch of the anterior interosseous artery. It can be used as a free skin flap, osteoperiosteal or osteocutaneous transfer. Reinnervation is possible. Indications in hand surgery are numerous. Five consecutive cases have been operated upon successfully.
Three successful cases of distal finger replantation are described where suitable veins were unavailable for anastomosis after arterial flow had been re-established. To prevent infarction, calcium heparin was injected subcutaneously into the replants at intervals over 9 days. This allowed the venous blood to escape into the dressings while an adequate microvenous circulation was re-established, thus simulating the effect of a leech. Complete survival of all three distal replantations was observed. No attempted case has been unsuccessful. The procedure is simple and can be administered by the nursing staff. It avoids some of the problems associated with the use of medicinal leeches and systemic heparin. Applications of this technique in other areas of replantation and flap surgery are suggested.
In 7 cases involving 8 fingers, amputation of the distal phalanx of the finger with defects of the pulp were covered by island flaps with the digital vessels acting as reverse vascular pedicles. The survival of the island flap was successful in all cases. The vascularisation of the island flap is derived from the digital palmar arch which is the anastomosis between the radial and ulnar sides of the finger. This method uses a single operative field and covers the defect with volar skin having similar qualities. However, due to problems in sensory recovery, we limit the indications for this method to the middle, ring and little fingers of the non-dominant hand.
Two cases of successful digital replantation are presented in which arterial inflow was provided by a proximal arterial-to-distal venous anastomosis. This technique provides an alternative means for replantation when no suitable artery for anastomosis is available in the amputated part.
For the treatment of skin defects with poor blood supply on the lateral aspects of the fingers, particularly the radial side of the index finger and the ulnar side of the little finger which have been difficult to cover conventionally, we have developed the sliding venous flap. The flap can be moved by using the "sag" obtained from the dissected dorsal veins of the same finger. We have applied this technique in six cases with excellent results. The indications are limited to cases with only slight crushing of the dorsum of the finger. We consider this technique safe and effective in covering skin defects with poor blood supply on the lateral aspects of fingers.
Free transfers of the distal parts of the second toe for reconstruction of distal phalangeal losses of the fingers were successfully carried out. This method is believed to be the best for functional and cosmetic reasons, but major postoperative vascular problems exist. To overcome these problems, multiple vascular anastomoses were employed at operation. The indications for this method are limited in Japanese patients, and its use depends on the patient's age, sex, religious beliefs and the shape of the second toe.
Claw nail deformities of the fingers have been repaired by many methods, but the results have been cosmetically unsatisfactory because of loss of the distal phalangeal bone and the short nail bed. We have employed a trimmed second toetip including the distal phalangeal bone and excluding the germinal matrix as a vascularised composite flap for two patients with claw nail deformity of the fingers. The advantages of this method are that the repaired nail regrows to normal size and has bilateral nail folds. We believe that, in comparison with other conventional local or island flaps, this composite flap is functionally and cosmetically ideal for the repair of claw nail deformities.
Ninety-five patients with 98 complete or incomplete amputations of digits are reviewed. Three levels are considered according to the bony lesion, zone III being distal to the nail matrix. In this area, artery, nerve and vein repair need special techniques. The use of leeches in the absence of vein repair does not preclude an acceptable survival rate (68%), compared to the overall series (65.5%); however, smoking is detrimental (52%). Distal replantation is a fast and worthwhile procedure providing acceptable sensibility, no PIP limitation and good appearance at the price of a mean 74 days off work.
Free osteo-onychocutaneous flaps from the big toe have frequently been used for the reconstruction of distal phalangeal loss of the fingers. The thickness of the fatty tissue, however, makes these flaps bulky. We believe this disadvantage can be overcome with a free thin osteo-onychocutaneous flap from the big toe and consider this thin composite flap to be a superior method of reconstruction for the treatment of distal phalangeal loss.
Four types of the reverse digital artery flap--standard, extended, and innervated standard and extended--were developed for 52 finger defects. The arising pattern of the dorsal branch which was included in the innervated flap was studied and classified in cadaver dissections. Topographically, the described "Lai's line" is a useful guide to locate the underlying digital artery. Refinements in flap design and surgical technique resulted in favourable functional and cosmetic results. The average two-point discrimination of the reconstructed fingertip was 6.8 mm and 3.9 mm in the noninnervated and innervated flaps, respectively. This versatile flap is an ideal and reliable option for one-stage reconstruction of various finger defects.
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To provide sensation to the reverse digital artery (RDA) flap, both the dorsal branch from the proper digital nerve and the superficial sensory branch from the corresponding radial or ulnar nerve are sectioned at their proximal ends and included with the RDA flap. These are then anastomosed with the distal ends of both radial and ulnar digital nerves at the recipient wound. Three cases of pulp defects reconstructed by this technique achieved very favourable functional and cosmetic results. The RDA flap, innervated through bilateral neurorrhaphy, seems to be an excellent option for one-stage reconstruction of major pulp defects.
The authors propose a volar subcutaneous pedicled flap to cover skin defects over the dorsum of the same finger. This flap includes all the subcutaneous (adipofascial) tissues from the reticular dermis to the synovial sheath of the flexor tendons. After elevation of the dermo-epidermal flap, the subcutaneous tissues are raised as a flap pedicled laterally on one of the collateral arteries which constitutes the axis of rotation and transposition. After release of the collateral neurovascular bundle from its connections with the skeleton, the skin and the synovial sheath, the flap can be transposed to the dorsum of the finger and then covered with a split thickness skin graft. The advantages of this technique are: (1) No functional or cosmetic sequelae at the donor site which is closed by the volar dermo-epidermal flap; (2) Homodigital flap. This is particularly helpful in cases of multidigit involvement where cross-finger flaps cannot be performed; (3) Vascular reliability; (4) Preservation of both collateral arteries.
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A technique using a local composite neurovascular island flap, raised on the volar digital vessels and nerve, is described as a primary procedure for the reconstruction of extensive pulp loss of the fingertip. The results of this technique have been uniformly satisfactory in 8 patients.
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Treatment of severely comminuted unstable intra-articular finger fractures has three goals: reconstruction of the articular surfaces, prevention of redislocation of those surfaces, and proper healing of the capsuloligamentous apparatus. Dynamic circle traction (DCT), as described by Schenck (1986), is based on these principles and is the first method of treatment combining traction with intermittent or continuous passive motion. In order to improve on this method we applied continuous, instead of intermittent, passive motion in a newly developed DCT-device (continuous dynamic circle-traction = CDCT). Its first clinical use is discussed below. Our results with DCT, in eight patients, and CDCT, in four patients, are encouraging. Full function was regained at follow-up, in both groups, in three-quarters of the metacarpophalangeal (MCP) and half of the proximal interphalangeal (PIP) joints involved. Average loss of range of motion of the other MCP and PIP joints was 3.7 degrees and 5.6 degrees respectively. Treatment with CDCT may yield better results than DCT; the small number of patients treated and the relatively short period of follow-up does not justify comparison of both methods.