Journal of Hand Surgery (European Volume) http://jhs.sagepub.com/
Homodigital artery flap reconstruction for fingertip amputation: a comparative study of the oblique triangular neurovascular advancement flap and the reverse digital artery island flap S. Usami, S. Kawahara, T. Yamaguchi and Y. Hirase J Hand Surg Eur Vol published online 3 December 2013 DOI: 10.1177/1753193413515134 The online version of this article can be found at: http://jhs.sagepub.com/content/early/2013/11/29/1753193413515134
Published by: http://www.sagepublications.com
On behalf of: British Society for Surgery of the Hand
Additional services and information for Journal of Hand Surgery (European Volume) can be found at: Email Alerts: http://jhs.sagepub.com/cgi/alerts Subscriptions: http://jhs.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
>> OnlineFirst Version of Record - Dec 3, 2013 What is This?
Downloaded from jhs.sagepub.com at TEXAS SOUTHERN UNIVERSITY on November 28, 2014
515134 research-article2013
JHS0010.1177/1753193413515134The Journal of Hand SurgeryUsami et al.
JHS(E)
Full length article
Homodigital artery flap reconstruction for fingertip amputation: a comparative study of the oblique triangular neurovascular advancement flap and the reverse digital artery island flap
The Journal of Hand Surgery (European Volume) 0E(0) 1–7 © The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1753193413515134 jhs.sagepub.com
S. Usami1, S. Kawahara1, T. Yamaguchi1 and Y. Hirase2 Abstract This fingertip reconstruction study retrospectively compared sensory recovery and active range of motion outcomes in neurovascular island advancement and reverse digital artery island flaps. Seventeen oblique triangular flaps and 14 reverse digital artery island flaps were performed for nail bed level fingertip amputations (Ishikawa subzone II). There was no significant difference between the two procedures in the Semmes–Weinstein monofilament test and range of motion results. For static and moving two-point discrimination tests, however, those with a reverse digital artery island flap required a longer period for sensory recovery compared to those with an oblique triangular advancement flap. This trend equilibrated at 12 months after surgery showing no significant difference in both static and moving two-point discrimination tests between the procedures. Keywords Fingertip defect, homodigital artery flap, oblique triangular flap, reverse digital artery island flap Date received: 22nd January 2013; revised: 19th June 2013; accepted: 2nd November 2013
Introduction Homodigital artery flap reconstruction is known to provide satisfactory texture and cosmetic appearance as well as favourable sensibility (Lemmon et al., 2008). Among several different homodigital artery flap reconstruction methods, the oblique triangular advancement flap (OTF) (Venkataswami and Subramanian, 1980) and reverse digital artery island flap (RDAF) (Kojima et al., 1990) have been found to be very useful and are commonly used for the reconstruction of fingertip amputations. The nature of these flaps allows the surgical scars to affect only one side of the finger. The dorsal surface of the finger remains intact unlike other homodigital flaps, such as the homodigital dorsal middle phalangeal neurovascular advancement flap (Ozaksar et al., 2010) or dorsally extended digital island flap (Iwasawa et al., 2011). Because the OTF includes a neurovascular bundle, immediate recovery of sensation is expected. Despite the fact that the RDAF does not include digital nerves, Han et al. (2004) reported that patients showed good sensory recovery in the long term. In general, choosing to use an
OTF or RDAF depends on the level of amputation and required flap size. In cases of distal amputation through the nail bed, such as the subzone II amputation (Ishikawa et al. 1990) (Figure 1), there is no definitive evidence that one procedure is better than the other. In this study, we retrospectively evaluated the OTF and RDAF in subzone II level fingertip amputations, examining the recovery in fingertip sensation and range of motion.
1Department
of Orthopaedic Surgery, Tokyo Hand Surgery & Sports Medicine Institute, Takatsuki Orthopaedic Hospital, Tokyo, Japan 2Yotsuya Medical Cube Hand Surgery and Microsurgery Center, Tokyo, Japan Corresponding author:
Satoshi Usami, MD, Department of Orthopaedic Surgery, Tokyo Hand Surgery & Sports Medicine Institute, Takatsuki Orthopaedic Hospital, 360 Takatsukicho, Hachioji, Tokyo, 192-0002, Japan. Email: [email protected]
Downloaded from jhs.sagepub.com at TEXAS SOUTHERN UNIVERSITY on November 28, 2014
2
The Journal of Hand Surgery (Eur) 0E(0) s2PD, m2PD, and %TAM were statistically analyzed using Student’s t-test (variances in the two groups were assumed to be equal) or Welch’s t-test (not equal). The results of presence or absence of subjective numbness and Tinel’s sign were analyzed using Fisher’s exact test. We encouraged range of motion exercises from 1 week after the operation. None of the patients received sensory education or desensitisation therapy.
Surgical technique
Figure 1. Ishikawa’s classification of the amputated finger.
Methods From September 2009 to December 2011, we performed 52 reconstructive procedures for fingertip amputations using either the OTF or insensate RDAF (30 OTF and 22 RDAF). Thirty-one of the 52 cases were included on the basis of (1) Ishikawa subzone II amputation; (2) finger injuries excluding the thumb; (3) only one finger involved. All patients were followed for more than 6 (range 6–21, mean 12.5) months. Patient age ranged from 22 to 81 (mean 47.9) years. OTF was used in 17 fingers (16 males and one female) and RDAF in 14 fingers (12 males and two females). Nineteen flaps were used as salvage following failed finger replantations (11 OTF and eight RDAF), and the other 12 flaps were the primary procedure for the fingertip defect (six OTF and six RDAF). In total, 11 index, nine middle, 10 ring, and one little finger were involved (Tables 1 and 2). Sensory evaluation was conducted using the Semmes–Weinstein (S-W) monofilament test, static two-point discrimination test (s2PD), and moving two-point discrimination test (m2PD). Tinel’s sign on the flap as well as subjective assessment of numbness and tingling were documented. We used total active motion (TAM) to evaluate mobility. TAM was defined as the ratio of the total arc of motion in the affected digits compared with the contralateral digits, and was recorded for the distal interphalangeal (DIP), proximal interphalangeal (PIP), and metacarpophalangeal (MP) joints. We compared the outcomes of OTF and RDAF in all 31 patients followed for more than 6 months and in 19 patients followed for more than 12 (range 12–21, mean 15.8) months. The results of the S-W test,
The flap design of the OTF consisted of a mid-lateral incision and volar oblique incision. The neurovascular bundle is easily found at the proximal phalangeal level. After that, the flap was raised above the tendon sheath from the distal fingertip defect area to the MP joint. With this dissection, the flap can be advanced as much as 15 mm to the fingertip without any tension to the neurovascular bundle (Figure 2). After advancement of this flap, we can make a fingertip plasty with free nail bed graft transfer or eponychial flap (Fakin et al., 2013) for the natural nail bed restoration. The RDAF is designed at the lateral area of damaged finger, and the required flap size is 20% bigger than the defect size. The neurovascular bundle is easily found at the proximal phalangeal level. This flap is raised with the digital artery but preserving the digital nerve with the finger. After the digital artery is ligated at the proximal base, we turn the flap 180° at the pivot point, which is located at the mid-middle phalangeal level, to reach the flap at the fingertip defect. No neurorrhaphy is performed. Skin grafting covers the flap donor site (Figure 3). No difficulties from inflammation or adhesion were encountered when harvesting these flaps, even after failed finger re-plantations.
Result All flaps survived, and there were no donor site problems. For all 31 patients followed for more than 6 months (mean follow-up 12.5 months), those who had RDAF (mean follow-up 13.1 months) showed slower sensory recovery compared with those who had OTF (mean follow-up 12.1 months), as indicated by s2PD (p = .038) and m2PD (p = .045), although S-W tests showed no significant difference between OTF and RDAF. Percentage TAM, subjective numbness and tingling, and Tinel’s sign were not significant between the two flaps (Table 3).
Downloaded from jhs.sagepub.com at TEXAS SOUTHERN UNIVERSITY on November 28, 2014
3
Usami et al. Table 1. Summary of patient data of the oblique triangular flap. Patient
Age
Sex Follow-Up
Injured
Flap advancement
%TAM
(mo)
finger
distance (mm)
(%)
21 19 19 15 14 14 14 13 12 12 10 9 8 7 7 6 6
R middle L middle L index L middle R ring R middle R little L ring R index L index L index L index L index L index L ring R index L index
10 11 11 10 9 13 8 7 7 9 8 12 12 8 10 9 8
97.9 95.6 83.2 91 93 93.3 100 95.7 81.4 92.3 86.2 100 69.3 100 96.7 88.4 81
number (y) 1 2 3 4 5 6 8 7 9 10 11 12 13 14 15 16 17
43 22 49 52 70 37 48 42 45 41 61 39 54 25 81 34 59
M M M M F M M M M M M M M M M M M
S-W test
3.84 3.61 2.83 4.31 4.31 4.31 3.22 3.84 3.61 3.22 3.84 3.61 3.84 3.61 4.31 4.31 4.56
s2PD
m2PD Numbness Tinel’s sign
(mm)
(mm)
6 4 5 7 8 10 5 7 6 4 8 8 5 3 10 5 9
5 2 5 9 5 9 4 6 3 6 8 5 3 2 6 5 7
N N N N N N N N Y N N N Y N N N Y
N N N Y N N N N N N N Y Y N N N Y
Numbness
Tinel’s sign
Table 2. Summary of patient data of the reverse digital artery island flap. Patient
Age
number
(y)
1 2 3 4 5 6 7 8 9 10 11 12 13 14
62 39 68 47 61 60 52 50 43 40 54 32 32 42
Sex
F M M M M M M M M F M M M M
Follow-up
Injured
Flap size
%TAM
(mo)
finger
(mm × mm)
(%)
19 19 19 17 16 15 15 14 13 8 8 7 7 6
L middle L middle L middle L ring R ring R ring L index R index L middle R ring L middle R ring R ring R ring
15 × 14 20 × 16 22 × 15 17 × 13 15 × 14 25 × 15 20 × 17 20 × 14 20 × 15 23 × 14 18 × 16 20 × 10 17 × 12 18 × 15
100 96.7 95.9 83.2 95.9 83 94 86.3 61 84.9 90.9 96.2 87.6 92.1
For the 19 patients observed for more than 12 months (OTF 10 flaps, mean follow-up 15.3 months; RDAF nine flaps, mean follow-up 16.3 months), the delay in 2PD observed in the early phase in the RDAF ultimately disappeared (s2PD: p = .34; m2PD: p = .78). The S-W test and %TAM showed no significant difference (Table 4). Three OTF patients (No. 9, 13, and 17) felt persistent numbness 6 months after the operation and hardly used the affected finger.
S-W Test
3.84 4.31 4.56 3.22 2.83 3.84 3.61 4.31 4.56 3.61 4.56 4.31 4.31 4.31
s2PD
m2PD
(mm)
(mm)
5 10 8 5 5 7 6 7 11 10 10 13 9 10
4 7 5 4 4 8 5 5 9 9 10 10 9 9
N N N N N Y Y N Y Y Y N N Y
N N N N N N Y N Y Y Y N N N
Four RDAF patients (No. 7, 9, 10, and 11) suffered persistent hypersensitivity. The decreased range of motion was caused by extension lag mainly due to the PIP or DIP joint, and flexion lag was hardly found. We observed mild PIP joint contractures in four patients in the OTF group (No. 3, 9, 13, and 17) and three patients in the RDAF group (No. 4, 6, and 8). Severe scar contractures were found in one patient (No. 9) who underwent reconstruction by RDAF.
Downloaded from jhs.sagepub.com at TEXAS SOUTHERN UNIVERSITY on November 28, 2014
4
The Journal of Hand Surgery (Eur) 0E(0)
Figure 2. A case of oblique triangular flap. (A) Patient number 6, a 37-year-old man injured at the right middle finger. Flap design. (B) Harvesting the flap with neurovascular bundle. (C) Oblique triangular flap was advanced 13 mm with Z-plasty in a proximal finger crease. (D, E) Post-operative appearance after 14 months. Moderate contracture remained at the PIP joint, but fingertip appearance was natural.
Discussion We can choose a suitable treatment for fingertip amputations for an individual patient. Sufficient and satisfactory healing is reported with nonsurgical procedures, such as semi-occlusive dressing (Hoigné et al., 2013), but this procedure needs several months for complete healing. Thus, we often select surgical procedures for fingertip reconstruction in anticipation of early return to work. The oblique triangular flap is a direct-flow advancement flap with a neurovascular bundle and can be advanced approximately 15 mm (Borman et al., 2000;
Venkataswami and Subramanian, 1980). Postoperative recovery in sensation is known to be fairly quick and favourable. Borman et al. (2000) reported that s2PD ranged from 3 to 8 mm at a mean follow-up of 4.2 months with a mean s2PD of 4.3 mm, and Varitimidis et al. (2005) reported similar results (s2PD ranged from 3 to 10 mm, mean 4 mm). In this study, s2PD and m2PD reached plateau after 6 months postoperatively, and all 17 OTF reconstructed digits attained good sensibility. Despite satisfactory recovery in sensation, OTF sometimes causes subjective sensory symptoms such as paresthesia. It can also
Downloaded from jhs.sagepub.com at TEXAS SOUTHERN UNIVERSITY on November 28, 2014
5
Usami et al.
Figure 3. A case of reverse digital artery island flap. (A) Patient number 13, a 32-year-old man injured at the right ring finger. The flap was designed at the ulnar side and its size was 17 × 12 mm. (B) Separating the common digital nerve from the flap. (C) Turning the flap at the pivot point. (D) The flap was stabilized in the fingertip defect. (E, F) Post-operative appearance after 7 months.
Table 3. Over 6 months of follow-up of 31 patients.
Patient Mean follow-up (mo) %TAM S-W test s2PD (mm) m2PD (mm) Numbness (%) Tinel’s sign (%)
OTF
RDAF
p value
17 12.1 (6–21) 90.9 (69.3–100) 3.83 (2.83–4.56) 6.5 (3–10) 5.3 (2–9) 17.6 (3/17) 23.5 (4/17)
14 13.1 (6–19) 89.1 (61–100) 4.01 (2.84–4.56) 8.3 (5–13) 7.0 (4–10) 42.9 (6/14) 28.6 (4/14)
0.59 0.59 0.39 0.038 0.045 0.13 0.53
result in PIP joint contracture, especially when the distance advanced is too long (Sano et al., 2008) or dissection of the neurovascular bundle is inadequate. Some authors advocate adding Z-plasty or step-ladder design in an effort to prevent scar contracture
(Borman et al., 2000; Evans and Martin, 1998). The alternative includes using a post-operative night splint, which has shown to be effective for the prevention of joint contracture (Lanzetta et al., 1995). We used a night splint (PIP extension splint) for seven
Downloaded from jhs.sagepub.com at TEXAS SOUTHERN UNIVERSITY on November 28, 2014
6
The Journal of Hand Surgery (Eur) 0E(0)
Table 4. Over 12 months of follow-up of 19 patients.
Patients Mean follow-up (mo) %TAM S-W test s2PD (mm) m2PD (mm) Numbness (%) Tinel’s sign (%)
OTF
RDAF
p value
10 15.3 (12–21) 92.3 (81.4–100) 3.71 (2.83–4.31) 6.2 (4–10) 5.4 (2–9) 10 (1/10) 10 (1/10)
9 16.3 (13–19) 88.4 (61–100) 3.9 (2.83–4.56) 7.1 (5–11) 5.7 (4–9) 33.3 (3/9) 22 (2/9)
0.43 0.38 0.47 0.34 0.78 0.25 0.46
patients found with a joint contracture after operation, but despite this, a mild PIP joint contracture was observed in four patients. The reverse digital artery island flap is a reverseflow flap through the communicating branch between both common digital arteries at the middle phalangeal level (Kojima et al., 1990). By raising this flap from the lateral aspect of the affected digit at the proximal phalangeal level, occasionally extending proximally to the dorsal MP joint level, coverage of the large fingertip defect is feasible. Another advantage of this flap is that it is capable of being a sensate flap by including a dorsal digital nerve or dorsal branch of the common digital nerve for coaptation (Lai et al., 1993). Quick recovery of sensation can be expected with a sensate flap, and Han et al. (1998) reported that s2PD of sensate flaps became 6.2 mm in 12 fingers, and s2PD of insensate flaps became 10.2 mm in 34 fingers at over 6 months of follow-up. Han et al. (2004) reported that there is no difference between sensate and insensate flaps regarding sensory recovery and subjective view at a follow-up of more than 1 year. This phenomenon is considered to be due to re-innervation of the peripheral nerves around the flap (Sapp et al., 1993), and we observed a similar phenomenon after replantation of fingertip amputation (Ozcelik et al., 2008). We believe that two important things are needed for good recovery of sensation: one is to harvest an adequately vascularized flap without congestion, and the other is to select a tissue flap that is similar to the defected tissue. The innervated RDAF has disadvantages, namely, the need for a microscope when suturing the digital nerve and longer operative time. Moreover, it is sometimes difficult to arrange the flap for neurorrhaphy, causing the flap pedicle to twist or suffer excessive tension. For this reason, we did not use the sensate flap procedure actively. In this study, s2PD and m2PD were initially different as one would expect given the intact nerve supply to the OTF; however, the S-W test showed no difference between two procedures. We think that
one reason for this is the difference in skin hardness and texture. Dellon et al. (1995) reported the positive correlation between cutaneous pressure threshold for one-point static touch (like a S-W test) and skin hardness, but there is no relationship between skin hardness and s2PD or m2PD. The lateral finger base skin used for the RDAF is more soft and sensitive than the fingertip volar skin used for the OTF, perhaps accounting for the similarity seen in S-W testing. Interestingly, those who had sustained numbness or Tinel’s sign for more than 6 months after fingertip reconstruction with OTF were prone to complain of hypersensitivity in the long term. We think that the hypersensitivity to OTF is caused by adhesion of the digital nerve, as this sensory disturbance does not disappear naturally over time. On the other hand, the hypersensitivity seen in RDAF is caused by reinnervation of the peripheral nerves, and this phenomenon is usually temporary until sensory recovery is completed. All patients reconstructed with RDAF felt hypersensitivity initially, but this persisted in only four patients (No. 7, 9, 10, and 11). The functional outcome between OTF and RDAF was very similar in both sensory and motor function in the medium-term when used for the reconstruction of through nail bed subzone II fingertip defects. The oblique triangular flap is the procedure of choice for transverse defects and oblique defects in the lateral aspect at subzone I or II. However, for volar oblique defects that require abundant flap volume, the reverse digital artery island flap is felt to be more appropriate in many cases. The selection of these flaps should be based on various factors, such as expected post-operative complications, scar, whether a skin graft is acceptable to the patient, and patient background, but not neurological requirement, as both the OFT and RDAF have similar neurological outcomes. Acknowledgement I am deeply grateful to the anonymous reviewers.
Downloaded from jhs.sagepub.com at TEXAS SOUTHERN UNIVERSITY on November 28, 2014
7
Usami et al. Conflict of interests Authors have no conflicts of interest.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References Borman H, Maral T, Tancer M. Fingertip reconstruction using two variations of direct-flow homodigital neurovascular island flaps. Ann Plast Surg. 2000, 45: 24–30. Dellon ES, Keller K, Moratz A, Dellon AL. The relationships between skin hardness, pressure perception and twopoint discrimination in the fingertip. J Hand Surg Br. 1995, 20: 44–8. Evans DM, Martin DL. Step-advancement island flap for fingertip reconstruction. Br J Plast Surg. 1998, 41: 105–11. Fakin RM, Biraima A, Klein H, Giovanoli P, Calcagni M. Primary functional and aesthetic restoration of the fingernail in distal fingertip amputations with the eponychial flap. J Hand Surg Eur. 2013 (epub). Han SK, Lee BI, Kim WK. The reverse digital artery island flap: Clinical experience in 120 fingers. Plast Reconstr Surg. 1998, 101: 1006–11. Han SK, Lee BI, Kim WK. The reverse digital artery island flap: an update. Plast Reconstr Surg. 2004, 113: 1753–5. Hoigné D, Hug U, Schürch M, Meoli M, von Wartburg U. Semi-occlusive dressing for the treatment of fingertip amputations with exposed bone: quantity and quality of soft-tissue regeneration. J Hand Surg Eur. 2013 (epub). Ishikawa K, Ogawa Y, Soeda H, Yoshida Y. [A new classification of the amputation level for the distal part of the fingers.] J Jpn Soc Microsurg. 1990, 3: 54–62. Iwasawa M, Kawamura T, Nagai F. Dorsally extended digital island flap for repairing soft tissue injury of
the fingertip. J Plast Reconstr Aesthet Surg. 2011, 64: 1300–5. Kojima T, Tsuchida Y, Hirase Y, Endo T. Reverse vascular pedicle digital island flap. Br J Plast Surg. 1990, 43: 290–5. Lai CS, Lin SD, Chou CK, Tsai CW. Innervated reverse digital artery flap through bilateral neurorrhaphy for pulp defects. Br J Plast Surg. 1993, 36: 483–8. Lanzetta M, Mastropasqua B, Chollet A, Brisebois N. Versatility of the homodigital triangular neurovascular island flap in fingertip reconstruction. J Hand Surg Br. 1995, 20: 824–9. 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. Ozaksar K, Toros T, Sugun TS et al. Reconstruction of finger pulp defects using homodigital dorsal middle phalangeal neurovascular advancement flap. J Hand Surg Eur. 2010, 35: 125–9. Ozcelik IB, Tuncer S, Purisa H et al. Seonsory outcome of fingertip replantation without nerve repair. Microsurgery. 2008, 28: 524–30. Sano K, Ozeki S, Kimura K, Hyakusoku H. Relationship between sensory recovery and advancement distance of oblique triangular flap for fingertip reconstruction. J Hand Surg Am. 2008, 33: 1088–92. Sapp JW, Allen RJ, Dupin C. A reversed digital artery island flap for the treatment of fingertip injuries. J Hand Surg Am. 1993, 18: 528–34. Varitimidis SE, Dailiana AH, Zibis AH et al. Restoration of function and sensitivity utilizing a homodigital neurovascular island flap after amputation injuries of the fingertip. J Hand Surg Br. 2005, 30: 338–42. Venkataswami R, Subramanian N. Oblique triangular flap: a new method of repair for oblique amputation of the fingertip and thumb. Plast Reconstr Surg. 1980, 66: 296–300.
Downloaded from jhs.sagepub.com at TEXAS SOUTHERN UNIVERSITY on November 28, 2014
Homodigital artery flap reconstruction for fingertip amputation: a comparative study of the oblique triangular neurovascular advancement flap and the reverse digital artery island flap S. Usami, S. Kawahara, T. Yamaguchi and Y. Hirase J Hand Surg Eur Vol published online 3 December 2013 DOI: 10.1177/1753193413515134 The online version of this article can be found at: http://jhs.sagepub.com/content/early/2013/11/29/1753193413515134
Published by: http://www.sagepublications.com
On behalf of: British Society for Surgery of the Hand
Additional services and information for Journal of Hand Surgery (European Volume) can be found at: Email Alerts: http://jhs.sagepub.com/cgi/alerts Subscriptions: http://jhs.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
>> OnlineFirst Version of Record - Dec 3, 2013 What is This?
Downloaded from jhs.sagepub.com at TEXAS SOUTHERN UNIVERSITY on November 28, 2014
515134 research-article2013
JHS0010.1177/1753193413515134The Journal of Hand SurgeryUsami et al.
JHS(E)
Full length article
Homodigital artery flap reconstruction for fingertip amputation: a comparative study of the oblique triangular neurovascular advancement flap and the reverse digital artery island flap
The Journal of Hand Surgery (European Volume) 0E(0) 1–7 © The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1753193413515134 jhs.sagepub.com
S. Usami1, S. Kawahara1, T. Yamaguchi1 and Y. Hirase2 Abstract This fingertip reconstruction study retrospectively compared sensory recovery and active range of motion outcomes in neurovascular island advancement and reverse digital artery island flaps. Seventeen oblique triangular flaps and 14 reverse digital artery island flaps were performed for nail bed level fingertip amputations (Ishikawa subzone II). There was no significant difference between the two procedures in the Semmes–Weinstein monofilament test and range of motion results. For static and moving two-point discrimination tests, however, those with a reverse digital artery island flap required a longer period for sensory recovery compared to those with an oblique triangular advancement flap. This trend equilibrated at 12 months after surgery showing no significant difference in both static and moving two-point discrimination tests between the procedures. Keywords Fingertip defect, homodigital artery flap, oblique triangular flap, reverse digital artery island flap Date received: 22nd January 2013; revised: 19th June 2013; accepted: 2nd November 2013
Introduction Homodigital artery flap reconstruction is known to provide satisfactory texture and cosmetic appearance as well as favourable sensibility (Lemmon et al., 2008). Among several different homodigital artery flap reconstruction methods, the oblique triangular advancement flap (OTF) (Venkataswami and Subramanian, 1980) and reverse digital artery island flap (RDAF) (Kojima et al., 1990) have been found to be very useful and are commonly used for the reconstruction of fingertip amputations. The nature of these flaps allows the surgical scars to affect only one side of the finger. The dorsal surface of the finger remains intact unlike other homodigital flaps, such as the homodigital dorsal middle phalangeal neurovascular advancement flap (Ozaksar et al., 2010) or dorsally extended digital island flap (Iwasawa et al., 2011). Because the OTF includes a neurovascular bundle, immediate recovery of sensation is expected. Despite the fact that the RDAF does not include digital nerves, Han et al. (2004) reported that patients showed good sensory recovery in the long term. In general, choosing to use an
OTF or RDAF depends on the level of amputation and required flap size. In cases of distal amputation through the nail bed, such as the subzone II amputation (Ishikawa et al. 1990) (Figure 1), there is no definitive evidence that one procedure is better than the other. In this study, we retrospectively evaluated the OTF and RDAF in subzone II level fingertip amputations, examining the recovery in fingertip sensation and range of motion.
1Department
of Orthopaedic Surgery, Tokyo Hand Surgery & Sports Medicine Institute, Takatsuki Orthopaedic Hospital, Tokyo, Japan 2Yotsuya Medical Cube Hand Surgery and Microsurgery Center, Tokyo, Japan Corresponding author:
Satoshi Usami, MD, Department of Orthopaedic Surgery, Tokyo Hand Surgery & Sports Medicine Institute, Takatsuki Orthopaedic Hospital, 360 Takatsukicho, Hachioji, Tokyo, 192-0002, Japan. Email: [email protected]
Downloaded from jhs.sagepub.com at TEXAS SOUTHERN UNIVERSITY on November 28, 2014
2
The Journal of Hand Surgery (Eur) 0E(0) s2PD, m2PD, and %TAM were statistically analyzed using Student’s t-test (variances in the two groups were assumed to be equal) or Welch’s t-test (not equal). The results of presence or absence of subjective numbness and Tinel’s sign were analyzed using Fisher’s exact test. We encouraged range of motion exercises from 1 week after the operation. None of the patients received sensory education or desensitisation therapy.
Surgical technique
Figure 1. Ishikawa’s classification of the amputated finger.
Methods From September 2009 to December 2011, we performed 52 reconstructive procedures for fingertip amputations using either the OTF or insensate RDAF (30 OTF and 22 RDAF). Thirty-one of the 52 cases were included on the basis of (1) Ishikawa subzone II amputation; (2) finger injuries excluding the thumb; (3) only one finger involved. All patients were followed for more than 6 (range 6–21, mean 12.5) months. Patient age ranged from 22 to 81 (mean 47.9) years. OTF was used in 17 fingers (16 males and one female) and RDAF in 14 fingers (12 males and two females). Nineteen flaps were used as salvage following failed finger replantations (11 OTF and eight RDAF), and the other 12 flaps were the primary procedure for the fingertip defect (six OTF and six RDAF). In total, 11 index, nine middle, 10 ring, and one little finger were involved (Tables 1 and 2). Sensory evaluation was conducted using the Semmes–Weinstein (S-W) monofilament test, static two-point discrimination test (s2PD), and moving two-point discrimination test (m2PD). Tinel’s sign on the flap as well as subjective assessment of numbness and tingling were documented. We used total active motion (TAM) to evaluate mobility. TAM was defined as the ratio of the total arc of motion in the affected digits compared with the contralateral digits, and was recorded for the distal interphalangeal (DIP), proximal interphalangeal (PIP), and metacarpophalangeal (MP) joints. We compared the outcomes of OTF and RDAF in all 31 patients followed for more than 6 months and in 19 patients followed for more than 12 (range 12–21, mean 15.8) months. The results of the S-W test,
The flap design of the OTF consisted of a mid-lateral incision and volar oblique incision. The neurovascular bundle is easily found at the proximal phalangeal level. After that, the flap was raised above the tendon sheath from the distal fingertip defect area to the MP joint. With this dissection, the flap can be advanced as much as 15 mm to the fingertip without any tension to the neurovascular bundle (Figure 2). After advancement of this flap, we can make a fingertip plasty with free nail bed graft transfer or eponychial flap (Fakin et al., 2013) for the natural nail bed restoration. The RDAF is designed at the lateral area of damaged finger, and the required flap size is 20% bigger than the defect size. The neurovascular bundle is easily found at the proximal phalangeal level. This flap is raised with the digital artery but preserving the digital nerve with the finger. After the digital artery is ligated at the proximal base, we turn the flap 180° at the pivot point, which is located at the mid-middle phalangeal level, to reach the flap at the fingertip defect. No neurorrhaphy is performed. Skin grafting covers the flap donor site (Figure 3). No difficulties from inflammation or adhesion were encountered when harvesting these flaps, even after failed finger re-plantations.
Result All flaps survived, and there were no donor site problems. For all 31 patients followed for more than 6 months (mean follow-up 12.5 months), those who had RDAF (mean follow-up 13.1 months) showed slower sensory recovery compared with those who had OTF (mean follow-up 12.1 months), as indicated by s2PD (p = .038) and m2PD (p = .045), although S-W tests showed no significant difference between OTF and RDAF. Percentage TAM, subjective numbness and tingling, and Tinel’s sign were not significant between the two flaps (Table 3).
Downloaded from jhs.sagepub.com at TEXAS SOUTHERN UNIVERSITY on November 28, 2014
3
Usami et al. Table 1. Summary of patient data of the oblique triangular flap. Patient
Age
Sex Follow-Up
Injured
Flap advancement
%TAM
(mo)
finger
distance (mm)
(%)
21 19 19 15 14 14 14 13 12 12 10 9 8 7 7 6 6
R middle L middle L index L middle R ring R middle R little L ring R index L index L index L index L index L index L ring R index L index
10 11 11 10 9 13 8 7 7 9 8 12 12 8 10 9 8
97.9 95.6 83.2 91 93 93.3 100 95.7 81.4 92.3 86.2 100 69.3 100 96.7 88.4 81
number (y) 1 2 3 4 5 6 8 7 9 10 11 12 13 14 15 16 17
43 22 49 52 70 37 48 42 45 41 61 39 54 25 81 34 59
M M M M F M M M M M M M M M M M M
S-W test
3.84 3.61 2.83 4.31 4.31 4.31 3.22 3.84 3.61 3.22 3.84 3.61 3.84 3.61 4.31 4.31 4.56
s2PD
m2PD Numbness Tinel’s sign
(mm)
(mm)
6 4 5 7 8 10 5 7 6 4 8 8 5 3 10 5 9
5 2 5 9 5 9 4 6 3 6 8 5 3 2 6 5 7
N N N N N N N N Y N N N Y N N N Y
N N N Y N N N N N N N Y Y N N N Y
Numbness
Tinel’s sign
Table 2. Summary of patient data of the reverse digital artery island flap. Patient
Age
number
(y)
1 2 3 4 5 6 7 8 9 10 11 12 13 14
62 39 68 47 61 60 52 50 43 40 54 32 32 42
Sex
F M M M M M M M M F M M M M
Follow-up
Injured
Flap size
%TAM
(mo)
finger
(mm × mm)
(%)
19 19 19 17 16 15 15 14 13 8 8 7 7 6
L middle L middle L middle L ring R ring R ring L index R index L middle R ring L middle R ring R ring R ring
15 × 14 20 × 16 22 × 15 17 × 13 15 × 14 25 × 15 20 × 17 20 × 14 20 × 15 23 × 14 18 × 16 20 × 10 17 × 12 18 × 15
100 96.7 95.9 83.2 95.9 83 94 86.3 61 84.9 90.9 96.2 87.6 92.1
For the 19 patients observed for more than 12 months (OTF 10 flaps, mean follow-up 15.3 months; RDAF nine flaps, mean follow-up 16.3 months), the delay in 2PD observed in the early phase in the RDAF ultimately disappeared (s2PD: p = .34; m2PD: p = .78). The S-W test and %TAM showed no significant difference (Table 4). Three OTF patients (No. 9, 13, and 17) felt persistent numbness 6 months after the operation and hardly used the affected finger.
S-W Test
3.84 4.31 4.56 3.22 2.83 3.84 3.61 4.31 4.56 3.61 4.56 4.31 4.31 4.31
s2PD
m2PD
(mm)
(mm)
5 10 8 5 5 7 6 7 11 10 10 13 9 10
4 7 5 4 4 8 5 5 9 9 10 10 9 9
N N N N N Y Y N Y Y Y N N Y
N N N N N N Y N Y Y Y N N N
Four RDAF patients (No. 7, 9, 10, and 11) suffered persistent hypersensitivity. The decreased range of motion was caused by extension lag mainly due to the PIP or DIP joint, and flexion lag was hardly found. We observed mild PIP joint contractures in four patients in the OTF group (No. 3, 9, 13, and 17) and three patients in the RDAF group (No. 4, 6, and 8). Severe scar contractures were found in one patient (No. 9) who underwent reconstruction by RDAF.
Downloaded from jhs.sagepub.com at TEXAS SOUTHERN UNIVERSITY on November 28, 2014
4
The Journal of Hand Surgery (Eur) 0E(0)
Figure 2. A case of oblique triangular flap. (A) Patient number 6, a 37-year-old man injured at the right middle finger. Flap design. (B) Harvesting the flap with neurovascular bundle. (C) Oblique triangular flap was advanced 13 mm with Z-plasty in a proximal finger crease. (D, E) Post-operative appearance after 14 months. Moderate contracture remained at the PIP joint, but fingertip appearance was natural.
Discussion We can choose a suitable treatment for fingertip amputations for an individual patient. Sufficient and satisfactory healing is reported with nonsurgical procedures, such as semi-occlusive dressing (Hoigné et al., 2013), but this procedure needs several months for complete healing. Thus, we often select surgical procedures for fingertip reconstruction in anticipation of early return to work. The oblique triangular flap is a direct-flow advancement flap with a neurovascular bundle and can be advanced approximately 15 mm (Borman et al., 2000;
Venkataswami and Subramanian, 1980). Postoperative recovery in sensation is known to be fairly quick and favourable. Borman et al. (2000) reported that s2PD ranged from 3 to 8 mm at a mean follow-up of 4.2 months with a mean s2PD of 4.3 mm, and Varitimidis et al. (2005) reported similar results (s2PD ranged from 3 to 10 mm, mean 4 mm). In this study, s2PD and m2PD reached plateau after 6 months postoperatively, and all 17 OTF reconstructed digits attained good sensibility. Despite satisfactory recovery in sensation, OTF sometimes causes subjective sensory symptoms such as paresthesia. It can also
Downloaded from jhs.sagepub.com at TEXAS SOUTHERN UNIVERSITY on November 28, 2014
5
Usami et al.
Figure 3. A case of reverse digital artery island flap. (A) Patient number 13, a 32-year-old man injured at the right ring finger. The flap was designed at the ulnar side and its size was 17 × 12 mm. (B) Separating the common digital nerve from the flap. (C) Turning the flap at the pivot point. (D) The flap was stabilized in the fingertip defect. (E, F) Post-operative appearance after 7 months.
Table 3. Over 6 months of follow-up of 31 patients.
Patient Mean follow-up (mo) %TAM S-W test s2PD (mm) m2PD (mm) Numbness (%) Tinel’s sign (%)
OTF
RDAF
p value
17 12.1 (6–21) 90.9 (69.3–100) 3.83 (2.83–4.56) 6.5 (3–10) 5.3 (2–9) 17.6 (3/17) 23.5 (4/17)
14 13.1 (6–19) 89.1 (61–100) 4.01 (2.84–4.56) 8.3 (5–13) 7.0 (4–10) 42.9 (6/14) 28.6 (4/14)
0.59 0.59 0.39 0.038 0.045 0.13 0.53
result in PIP joint contracture, especially when the distance advanced is too long (Sano et al., 2008) or dissection of the neurovascular bundle is inadequate. Some authors advocate adding Z-plasty or step-ladder design in an effort to prevent scar contracture
(Borman et al., 2000; Evans and Martin, 1998). The alternative includes using a post-operative night splint, which has shown to be effective for the prevention of joint contracture (Lanzetta et al., 1995). We used a night splint (PIP extension splint) for seven
Downloaded from jhs.sagepub.com at TEXAS SOUTHERN UNIVERSITY on November 28, 2014
6
The Journal of Hand Surgery (Eur) 0E(0)
Table 4. Over 12 months of follow-up of 19 patients.
Patients Mean follow-up (mo) %TAM S-W test s2PD (mm) m2PD (mm) Numbness (%) Tinel’s sign (%)
OTF
RDAF
p value
10 15.3 (12–21) 92.3 (81.4–100) 3.71 (2.83–4.31) 6.2 (4–10) 5.4 (2–9) 10 (1/10) 10 (1/10)
9 16.3 (13–19) 88.4 (61–100) 3.9 (2.83–4.56) 7.1 (5–11) 5.7 (4–9) 33.3 (3/9) 22 (2/9)
0.43 0.38 0.47 0.34 0.78 0.25 0.46
patients found with a joint contracture after operation, but despite this, a mild PIP joint contracture was observed in four patients. The reverse digital artery island flap is a reverseflow flap through the communicating branch between both common digital arteries at the middle phalangeal level (Kojima et al., 1990). By raising this flap from the lateral aspect of the affected digit at the proximal phalangeal level, occasionally extending proximally to the dorsal MP joint level, coverage of the large fingertip defect is feasible. Another advantage of this flap is that it is capable of being a sensate flap by including a dorsal digital nerve or dorsal branch of the common digital nerve for coaptation (Lai et al., 1993). Quick recovery of sensation can be expected with a sensate flap, and Han et al. (1998) reported that s2PD of sensate flaps became 6.2 mm in 12 fingers, and s2PD of insensate flaps became 10.2 mm in 34 fingers at over 6 months of follow-up. Han et al. (2004) reported that there is no difference between sensate and insensate flaps regarding sensory recovery and subjective view at a follow-up of more than 1 year. This phenomenon is considered to be due to re-innervation of the peripheral nerves around the flap (Sapp et al., 1993), and we observed a similar phenomenon after replantation of fingertip amputation (Ozcelik et al., 2008). We believe that two important things are needed for good recovery of sensation: one is to harvest an adequately vascularized flap without congestion, and the other is to select a tissue flap that is similar to the defected tissue. The innervated RDAF has disadvantages, namely, the need for a microscope when suturing the digital nerve and longer operative time. Moreover, it is sometimes difficult to arrange the flap for neurorrhaphy, causing the flap pedicle to twist or suffer excessive tension. For this reason, we did not use the sensate flap procedure actively. In this study, s2PD and m2PD were initially different as one would expect given the intact nerve supply to the OTF; however, the S-W test showed no difference between two procedures. We think that
one reason for this is the difference in skin hardness and texture. Dellon et al. (1995) reported the positive correlation between cutaneous pressure threshold for one-point static touch (like a S-W test) and skin hardness, but there is no relationship between skin hardness and s2PD or m2PD. The lateral finger base skin used for the RDAF is more soft and sensitive than the fingertip volar skin used for the OTF, perhaps accounting for the similarity seen in S-W testing. Interestingly, those who had sustained numbness or Tinel’s sign for more than 6 months after fingertip reconstruction with OTF were prone to complain of hypersensitivity in the long term. We think that the hypersensitivity to OTF is caused by adhesion of the digital nerve, as this sensory disturbance does not disappear naturally over time. On the other hand, the hypersensitivity seen in RDAF is caused by reinnervation of the peripheral nerves, and this phenomenon is usually temporary until sensory recovery is completed. All patients reconstructed with RDAF felt hypersensitivity initially, but this persisted in only four patients (No. 7, 9, 10, and 11). The functional outcome between OTF and RDAF was very similar in both sensory and motor function in the medium-term when used for the reconstruction of through nail bed subzone II fingertip defects. The oblique triangular flap is the procedure of choice for transverse defects and oblique defects in the lateral aspect at subzone I or II. However, for volar oblique defects that require abundant flap volume, the reverse digital artery island flap is felt to be more appropriate in many cases. The selection of these flaps should be based on various factors, such as expected post-operative complications, scar, whether a skin graft is acceptable to the patient, and patient background, but not neurological requirement, as both the OFT and RDAF have similar neurological outcomes. Acknowledgement I am deeply grateful to the anonymous reviewers.
Downloaded from jhs.sagepub.com at TEXAS SOUTHERN UNIVERSITY on November 28, 2014
7
Usami et al. Conflict of interests Authors have no conflicts of interest.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References Borman H, Maral T, Tancer M. Fingertip reconstruction using two variations of direct-flow homodigital neurovascular island flaps. Ann Plast Surg. 2000, 45: 24–30. Dellon ES, Keller K, Moratz A, Dellon AL. The relationships between skin hardness, pressure perception and twopoint discrimination in the fingertip. J Hand Surg Br. 1995, 20: 44–8. Evans DM, Martin DL. Step-advancement island flap for fingertip reconstruction. Br J Plast Surg. 1998, 41: 105–11. Fakin RM, Biraima A, Klein H, Giovanoli P, Calcagni M. Primary functional and aesthetic restoration of the fingernail in distal fingertip amputations with the eponychial flap. J Hand Surg Eur. 2013 (epub). Han SK, Lee BI, Kim WK. The reverse digital artery island flap: Clinical experience in 120 fingers. Plast Reconstr Surg. 1998, 101: 1006–11. Han SK, Lee BI, Kim WK. The reverse digital artery island flap: an update. Plast Reconstr Surg. 2004, 113: 1753–5. Hoigné D, Hug U, Schürch M, Meoli M, von Wartburg U. Semi-occlusive dressing for the treatment of fingertip amputations with exposed bone: quantity and quality of soft-tissue regeneration. J Hand Surg Eur. 2013 (epub). Ishikawa K, Ogawa Y, Soeda H, Yoshida Y. [A new classification of the amputation level for the distal part of the fingers.] J Jpn Soc Microsurg. 1990, 3: 54–62. Iwasawa M, Kawamura T, Nagai F. Dorsally extended digital island flap for repairing soft tissue injury of
the fingertip. J Plast Reconstr Aesthet Surg. 2011, 64: 1300–5. Kojima T, Tsuchida Y, Hirase Y, Endo T. Reverse vascular pedicle digital island flap. Br J Plast Surg. 1990, 43: 290–5. Lai CS, Lin SD, Chou CK, Tsai CW. Innervated reverse digital artery flap through bilateral neurorrhaphy for pulp defects. Br J Plast Surg. 1993, 36: 483–8. Lanzetta M, Mastropasqua B, Chollet A, Brisebois N. Versatility of the homodigital triangular neurovascular island flap in fingertip reconstruction. J Hand Surg Br. 1995, 20: 824–9. 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. Ozaksar K, Toros T, Sugun TS et al. Reconstruction of finger pulp defects using homodigital dorsal middle phalangeal neurovascular advancement flap. J Hand Surg Eur. 2010, 35: 125–9. Ozcelik IB, Tuncer S, Purisa H et al. Seonsory outcome of fingertip replantation without nerve repair. Microsurgery. 2008, 28: 524–30. Sano K, Ozeki S, Kimura K, Hyakusoku H. Relationship between sensory recovery and advancement distance of oblique triangular flap for fingertip reconstruction. J Hand Surg Am. 2008, 33: 1088–92. Sapp JW, Allen RJ, Dupin C. A reversed digital artery island flap for the treatment of fingertip injuries. J Hand Surg Am. 1993, 18: 528–34. Varitimidis SE, Dailiana AH, Zibis AH et al. Restoration of function and sensitivity utilizing a homodigital neurovascular island flap after amputation injuries of the fingertip. J Hand Surg Br. 2005, 30: 338–42. Venkataswami R, Subramanian N. Oblique triangular flap: a new method of repair for oblique amputation of the fingertip and thumb. Plast Reconstr Surg. 1980, 66: 296–300.
Downloaded from jhs.sagepub.com at TEXAS SOUTHERN UNIVERSITY on November 28, 2014
