Goro Inoue and Yukihisa Tamura
ONE-STAGE REPAIR OF BOTH SKIN AND TENDON DIGITAL DEFECTS USING THE ARTERIALIZED VENOUS FLAP
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WITH PALMARIS LONGUS TENDON ABSTRACT A novel technique of composite free-flap and tendon transfer is introduced and used in four patients to repair complicated finger injuries involving loss of skin and tendon. This is a one-stage procedure, providing unbulky, high-quality tissue. Although the final range of motion was disappointing, with an average of 10°, there is justification for further clinical trials in patients with loss of skin and tendon in the digits. EDITORIAL NOTE. Drs. Inoue and Tamura extend their functional application of composite arterialized venous flow-through flaps to include the palmaris tendon. While they cannot prove this is a true vascularized tendon graft, it is very likely that the tendon is nourished by direct paratenon perforators. The idea is novel and a good one. The selection of cases, however (except for Case 3, extensor slip at the PIP joint), is probably not appropriate for the application of this flap. Cases 1 and 2 involve crush injuries at the DIP joint and would have been more aptly treated by DIP fusion. The substitute of a flexor tendon between the A2 and A4 pulley levels, as in Case 4, without pulley reconstruction, is not adequate and most certainly would lead to "bow stringing." Elliott H. Rose
The combined loss of skin and tendon of the fingers is not uncommon and is a challenging problem. In the past, these injuries have been managed with a regional or distant flap, with tendon grafting done as a secondary procedure. This technique involves a multistage procedure usually requiring considerable time. The arterialized venous flap is now a routine procedure in our clinic to resurface skin defects of the hand1 and we considered that, if a palmaris longus
tendon were taken as a composite unit, this might provide a potential donor graft. We have undertaken four arterialized venous flaps with a palmaris longus tendon attached, each having a follow-up period of longer than one year.
OPERATIVE TECHNIQUE The donor site was the flexor aspect of the ipsilateral forearm. After debridement of the recipient area, the size of the skin defect and the length of the vein and tendon required were measured. The planned flap was marked out on the distal forearm, just over a palmaris longus tendon (Fig. 1). The flap was raised, taking a vein and a palmaris longus tendon, together with surrounding paratenon (Fig. 2). The donor site was closed primarily. The flap was reversed and interposed between the arteries of the recipient area; both ends of the vein were anastomosed, resulting in arterial inflow and outflow only (A-A type). When no suitable recipient artery was available at the distal side, a subcutaneous vein was used for the outflow of the flap; thus, an arteriovenous fistula was constructed (A-V type). The tendon graft was sutured in position both proximally
Department of Orthopaedic Surgery, Division of Hand Surgery, Nagoya University School of Medicine, Japan Reprint requests-. Dr. Inoue, Dept. of Orthopaedic Surgery, Division of Hand Surgery (Bun-in), Nagoya University School of Medicine, 1-1-20 Daikominami, Higashi-ku, Nagoya 461, Japan Accepted for publication April 15, 1991 Copyright © 1991 byThieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
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JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 7, NUMBER 4
OCTOBER 1991
and distally with 4-0 nylon. The flap was sutured loosely in place without tension. When the graft was done to an extensor tendon, the involved joint was immobilized with temporary Kirschner wire intraarticular fixation in an extended position for four weeks; when it was done to a flexor tendon, the hand was immobilized for three weeks with a plaster splint. The flaps had a cyanotic appearance and marked edema for one or two weeks following the operation, but these conditions resolved in two or three weeks, presumably due to neovascularization from the surrounding tissue.
340
CASE REPORTS CASE 1. A 31-year old man injured his right middle finger in a press machine, fracturing the condyle of the middle phalanx and damaging the surrounding skin. On the day of injury, the middle phalanx fracture was stabilized with Kirschner wire and the wound was sutured. Eighteen days later, the patient presented with skin necrosis of the radial half of the DIP joint (Fig. 3A). At operation, necrotic tissues were excised, with a
Figure 2. The flap is raised along with a palmaris longus tendon (*), containing a subcutaneous vein (arrow). The dissection is performed by placing the tendon paratenon in the flap.
Downloaded by: Universite Laval. Copyrighted material.
Figure 1. The flap is outlined on the flexor aspect of the forearm just over a palmaris longus tendon.
Downloaded by: Universite Laval. Copyrighted material.
FLOW-THROUGH FLAP WITH PALMARIS LONGUS TENDON/INOUE, TAMURA
B
Figure 3. Case 1. A, Preoperative appearance at 18 days after injury. B, Intraoperative appearance showing extensive skin defect over the DIP joint of the middle finger, with loss of the terminal tendon and exposure of the bone. C, One year postoperatively, the patient had 10° of active ROM at the DIP joint.
resultant terminal tendon gap of 1.5 cm, and a bare middle phalanx without periosteum lay at the fracture site (Fig. 3B). An arterialized venous flap attached to a palmaris longus tendon was grafted to both skin and tendon defects of the involved finger, using arteriovenous anastomosis for inflow and venovenous anastomosis for outflow. The flap healed uneventfully but the fracture did not fuse. Six months after injury, a bone graft was performed. This was successful, but osteoarthritis of the DIP joint occurred, due to avascular necrosis of the condyle of the middle phalanx. One year after the initial surgery, the patient had a DIP range of motion of 20730°, with good color and contour of the flap (Fig. 3C). CASE 2. A 67-year-old man lacerated the dorsum
of the DIP joint of his left ring finger with an electric saw. On the day of injury, a distally-based flap was sutured and the DIP joint was temporarily stabilized with Kirschner wire in an extended position. Two weeks later, the distally-based flap became necrotic. At exploration, the terminal tendon was shredded over 5 mm, with loss of its bony insertion. A 1.5- x 1.5-cm arterialized venous flap containing a palmaris longus tendon was grafted, using the same procedure described in Case 1. The flap survived, although with 20 percent necrosis at the periphery. Two and a half years postoperatively, the patient had active range of motion of 40760° of flexion at the DIP joint. ,' CASE 3. A 31-year-old man sustained a crushing injury to his right middle fingerTfracfuring the proximal
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342
After irrigation of the wound for two weeks, necrotic tissues were excised, resulting in a 2- x 1-cm skin loss and a 1-cm tendon loss, with partially exposed bone beneath the gliding floor of the tendon (Fig. 4B). The skin loss was covered with an arterialized venous flap, and tendon loss was repaired with an interposition graft of the arterialized venous palmaris longus tendon. During the first six months postoperatively, the patient had no active ROM of the DIP joint, so flexor tenolysis was subsequently carried out. One year after the initial surgery, he had an active ROM of 20730° of the DIP joint (Fig. 4C).
DISCUSSION Complex finger injuries involving the extensor or flexor tendon are a common occurrence. The results are often the destruction of tissues including skin, tendons, joint capsule, periosteum, and even bone. Primary management is directed at controlling infection, providing soft tissue coverage, and restoring function. Methods of reconstruction for such defects have included local, regional, or distant flaps, and free tissue transfer, with tendon grafting at a later date. Each of these methods, however, has significant drawbacks limiting its clinical application. Local flaps may
A • • • • • •"»' i^^i^^HHi^^^HI B Figure 4. Case 4. A, Preoperative appearance of the index finger. B, Intraoperative appearance showing both skin and tendon loss with damaged tendon bed. (Continued on next page)
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phalanx. At another hospital, the fracture of the proximal phalanx was fixed with an intramedullary Kirschner wire. Three weeks later, he was referred to our hospital with extensive skin necrosis around the PIP joint of the involved finger. At operation, there was extensive loss of skin over the dorsum and palmar surfaces of the involved finger, together with loss of the extensor tendon, and bare bone over the PIP joint. A 3- x 7-cm arterialized venous flap with a 5-cm palmaris longus tendon transfer was performed, to reconstruct both skin and tendon defects, using arteriovenous anastomosis of both ends of the vein. The flap survived despite marginal necrosis. The patient had an active ROM of 40760° at the PIP joint at a follow-up of one year. Last seen at two years postoperatively, however, he had an ankylosing PIP joint, and DIP motion of 5720°. Radiographs demonstrated degenerative changes and palmar dislocation of the PIP joint, presumably due to avascular necrosis of the head of the proximal phalanx. CASE 4. A 39-year-old man sustained a crush injury to his left index finger, resulting in a small skin loss to the palmar aspect and in severing a flexor digitorum profundus tendon at the middle phalangeal level. At another hospital, the patient was treated with only a skin wound suture. Six weeks later, he was referred to our hospital because of skin necrosis and wound infection (Fig. 4A).
OCTOBER 1991
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FLOW-THROUGH FLAP WITH PALMARIS LONGUS TENDON/INOUE, TAMURA
Figure 4, cont. C, Appearance and ROM of the DIP joint of the index finger, one year postoperatively. Extension (right) and flexion (left).
not be possible because of inadequate tissue. Regional flaps may compromise adjacent digits, leading to joint stiffness. Distant flaps are multi-stage procedures that require prolonged immobilization. Conventional free-tissue transfer often yields bulky flaps that require thinning. The use of the arterialized venous flap incorporating a palmaris longus tendon for such defects has not been reported in the previous literature. Our technique offers a one-stage reconstruction that allows early motion of the digit and thus reduces stiffness. The donor site is acceptable, with no functional deficit. This is a thin flap, and an incorporated palmaris longus tendon may possibly reduce adhesions along its length, as the graft is surrounded by loose areolar tissue. There is a question as to whether this tendon is vascularized or nonvascularized. The answer is not yet available, as sufficient research has not yet been done. Perhaps results would be better, if these grafts were viable with an intact blood supply.2 Even if the tendon is nonvascularized, the common use of the palmaris longus for tendon graft still justifies our technique. The results of our procedure were not as good as expected. Possible explanations of the limited results are (1) all grafts were used in a severely damaged tendon bed with exposed bone; and (2) two patients developed degenerative changes of the involved joint
due to avascular necrosis of the condyle. However, since these injuries probably would have required arthrodesis of the involved joints, the results in these patients would suggest that further clinical trials are justified.
REFERENCES 1. 2.
Inoue G, Maeda N, Suzuki K: Resurfacing of skin defects of the hand using the arterialised venous flap. Brit I Plast Surg 43:135, 1990 Taylor GI, Townsend P: Composite free flap and tendon transfer: An anatomical study and a clinical technique. Brit J Plast Surg 32:170, 1979
ADDITIONAL REFERENCES Inada Y, Fukui A, Tamai S, etai: An experimental study of the venous flap: Investigation of the recipient vein. J Reconstr Microsurg 6:123, 1990 Inoue G, Maeda N. Arterialized venous flap coverage for skin defects of the hand or foot. I Reconstr Microsurg 4:259, 1988 Rose EH: Small flap coverage of hand and digit defects. Clin Plast Surg 16:427, 1989 343
ONE-STAGE REPAIR OF BOTH SKIN AND TENDON DIGITAL DEFECTS USING THE ARTERIALIZED VENOUS FLAP
Downloaded by: Universite Laval. Copyrighted material.
WITH PALMARIS LONGUS TENDON ABSTRACT A novel technique of composite free-flap and tendon transfer is introduced and used in four patients to repair complicated finger injuries involving loss of skin and tendon. This is a one-stage procedure, providing unbulky, high-quality tissue. Although the final range of motion was disappointing, with an average of 10°, there is justification for further clinical trials in patients with loss of skin and tendon in the digits. EDITORIAL NOTE. Drs. Inoue and Tamura extend their functional application of composite arterialized venous flow-through flaps to include the palmaris tendon. While they cannot prove this is a true vascularized tendon graft, it is very likely that the tendon is nourished by direct paratenon perforators. The idea is novel and a good one. The selection of cases, however (except for Case 3, extensor slip at the PIP joint), is probably not appropriate for the application of this flap. Cases 1 and 2 involve crush injuries at the DIP joint and would have been more aptly treated by DIP fusion. The substitute of a flexor tendon between the A2 and A4 pulley levels, as in Case 4, without pulley reconstruction, is not adequate and most certainly would lead to "bow stringing." Elliott H. Rose
The combined loss of skin and tendon of the fingers is not uncommon and is a challenging problem. In the past, these injuries have been managed with a regional or distant flap, with tendon grafting done as a secondary procedure. This technique involves a multistage procedure usually requiring considerable time. The arterialized venous flap is now a routine procedure in our clinic to resurface skin defects of the hand1 and we considered that, if a palmaris longus
tendon were taken as a composite unit, this might provide a potential donor graft. We have undertaken four arterialized venous flaps with a palmaris longus tendon attached, each having a follow-up period of longer than one year.
OPERATIVE TECHNIQUE The donor site was the flexor aspect of the ipsilateral forearm. After debridement of the recipient area, the size of the skin defect and the length of the vein and tendon required were measured. The planned flap was marked out on the distal forearm, just over a palmaris longus tendon (Fig. 1). The flap was raised, taking a vein and a palmaris longus tendon, together with surrounding paratenon (Fig. 2). The donor site was closed primarily. The flap was reversed and interposed between the arteries of the recipient area; both ends of the vein were anastomosed, resulting in arterial inflow and outflow only (A-A type). When no suitable recipient artery was available at the distal side, a subcutaneous vein was used for the outflow of the flap; thus, an arteriovenous fistula was constructed (A-V type). The tendon graft was sutured in position both proximally
Department of Orthopaedic Surgery, Division of Hand Surgery, Nagoya University School of Medicine, Japan Reprint requests-. Dr. Inoue, Dept. of Orthopaedic Surgery, Division of Hand Surgery (Bun-in), Nagoya University School of Medicine, 1-1-20 Daikominami, Higashi-ku, Nagoya 461, Japan Accepted for publication April 15, 1991 Copyright © 1991 byThieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
339
JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 7, NUMBER 4
OCTOBER 1991
and distally with 4-0 nylon. The flap was sutured loosely in place without tension. When the graft was done to an extensor tendon, the involved joint was immobilized with temporary Kirschner wire intraarticular fixation in an extended position for four weeks; when it was done to a flexor tendon, the hand was immobilized for three weeks with a plaster splint. The flaps had a cyanotic appearance and marked edema for one or two weeks following the operation, but these conditions resolved in two or three weeks, presumably due to neovascularization from the surrounding tissue.
340
CASE REPORTS CASE 1. A 31-year old man injured his right middle finger in a press machine, fracturing the condyle of the middle phalanx and damaging the surrounding skin. On the day of injury, the middle phalanx fracture was stabilized with Kirschner wire and the wound was sutured. Eighteen days later, the patient presented with skin necrosis of the radial half of the DIP joint (Fig. 3A). At operation, necrotic tissues were excised, with a
Figure 2. The flap is raised along with a palmaris longus tendon (*), containing a subcutaneous vein (arrow). The dissection is performed by placing the tendon paratenon in the flap.
Downloaded by: Universite Laval. Copyrighted material.
Figure 1. The flap is outlined on the flexor aspect of the forearm just over a palmaris longus tendon.
Downloaded by: Universite Laval. Copyrighted material.
FLOW-THROUGH FLAP WITH PALMARIS LONGUS TENDON/INOUE, TAMURA
B
Figure 3. Case 1. A, Preoperative appearance at 18 days after injury. B, Intraoperative appearance showing extensive skin defect over the DIP joint of the middle finger, with loss of the terminal tendon and exposure of the bone. C, One year postoperatively, the patient had 10° of active ROM at the DIP joint.
resultant terminal tendon gap of 1.5 cm, and a bare middle phalanx without periosteum lay at the fracture site (Fig. 3B). An arterialized venous flap attached to a palmaris longus tendon was grafted to both skin and tendon defects of the involved finger, using arteriovenous anastomosis for inflow and venovenous anastomosis for outflow. The flap healed uneventfully but the fracture did not fuse. Six months after injury, a bone graft was performed. This was successful, but osteoarthritis of the DIP joint occurred, due to avascular necrosis of the condyle of the middle phalanx. One year after the initial surgery, the patient had a DIP range of motion of 20730°, with good color and contour of the flap (Fig. 3C). CASE 2. A 67-year-old man lacerated the dorsum
of the DIP joint of his left ring finger with an electric saw. On the day of injury, a distally-based flap was sutured and the DIP joint was temporarily stabilized with Kirschner wire in an extended position. Two weeks later, the distally-based flap became necrotic. At exploration, the terminal tendon was shredded over 5 mm, with loss of its bony insertion. A 1.5- x 1.5-cm arterialized venous flap containing a palmaris longus tendon was grafted, using the same procedure described in Case 1. The flap survived, although with 20 percent necrosis at the periphery. Two and a half years postoperatively, the patient had active range of motion of 40760° of flexion at the DIP joint. ,' CASE 3. A 31-year-old man sustained a crushing injury to his right middle fingerTfracfuring the proximal
341
JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 7, NUMBER 4
342
After irrigation of the wound for two weeks, necrotic tissues were excised, resulting in a 2- x 1-cm skin loss and a 1-cm tendon loss, with partially exposed bone beneath the gliding floor of the tendon (Fig. 4B). The skin loss was covered with an arterialized venous flap, and tendon loss was repaired with an interposition graft of the arterialized venous palmaris longus tendon. During the first six months postoperatively, the patient had no active ROM of the DIP joint, so flexor tenolysis was subsequently carried out. One year after the initial surgery, he had an active ROM of 20730° of the DIP joint (Fig. 4C).
DISCUSSION Complex finger injuries involving the extensor or flexor tendon are a common occurrence. The results are often the destruction of tissues including skin, tendons, joint capsule, periosteum, and even bone. Primary management is directed at controlling infection, providing soft tissue coverage, and restoring function. Methods of reconstruction for such defects have included local, regional, or distant flaps, and free tissue transfer, with tendon grafting at a later date. Each of these methods, however, has significant drawbacks limiting its clinical application. Local flaps may
A • • • • • •"»' i^^i^^HHi^^^HI B Figure 4. Case 4. A, Preoperative appearance of the index finger. B, Intraoperative appearance showing both skin and tendon loss with damaged tendon bed. (Continued on next page)
Downloaded by: Universite Laval. Copyrighted material.
phalanx. At another hospital, the fracture of the proximal phalanx was fixed with an intramedullary Kirschner wire. Three weeks later, he was referred to our hospital with extensive skin necrosis around the PIP joint of the involved finger. At operation, there was extensive loss of skin over the dorsum and palmar surfaces of the involved finger, together with loss of the extensor tendon, and bare bone over the PIP joint. A 3- x 7-cm arterialized venous flap with a 5-cm palmaris longus tendon transfer was performed, to reconstruct both skin and tendon defects, using arteriovenous anastomosis of both ends of the vein. The flap survived despite marginal necrosis. The patient had an active ROM of 40760° at the PIP joint at a follow-up of one year. Last seen at two years postoperatively, however, he had an ankylosing PIP joint, and DIP motion of 5720°. Radiographs demonstrated degenerative changes and palmar dislocation of the PIP joint, presumably due to avascular necrosis of the head of the proximal phalanx. CASE 4. A 39-year-old man sustained a crush injury to his left index finger, resulting in a small skin loss to the palmar aspect and in severing a flexor digitorum profundus tendon at the middle phalangeal level. At another hospital, the patient was treated with only a skin wound suture. Six weeks later, he was referred to our hospital because of skin necrosis and wound infection (Fig. 4A).
OCTOBER 1991
Downloaded by: Universite Laval. Copyrighted material.
FLOW-THROUGH FLAP WITH PALMARIS LONGUS TENDON/INOUE, TAMURA
Figure 4, cont. C, Appearance and ROM of the DIP joint of the index finger, one year postoperatively. Extension (right) and flexion (left).
not be possible because of inadequate tissue. Regional flaps may compromise adjacent digits, leading to joint stiffness. Distant flaps are multi-stage procedures that require prolonged immobilization. Conventional free-tissue transfer often yields bulky flaps that require thinning. The use of the arterialized venous flap incorporating a palmaris longus tendon for such defects has not been reported in the previous literature. Our technique offers a one-stage reconstruction that allows early motion of the digit and thus reduces stiffness. The donor site is acceptable, with no functional deficit. This is a thin flap, and an incorporated palmaris longus tendon may possibly reduce adhesions along its length, as the graft is surrounded by loose areolar tissue. There is a question as to whether this tendon is vascularized or nonvascularized. The answer is not yet available, as sufficient research has not yet been done. Perhaps results would be better, if these grafts were viable with an intact blood supply.2 Even if the tendon is nonvascularized, the common use of the palmaris longus for tendon graft still justifies our technique. The results of our procedure were not as good as expected. Possible explanations of the limited results are (1) all grafts were used in a severely damaged tendon bed with exposed bone; and (2) two patients developed degenerative changes of the involved joint
due to avascular necrosis of the condyle. However, since these injuries probably would have required arthrodesis of the involved joints, the results in these patients would suggest that further clinical trials are justified.
REFERENCES 1. 2.
Inoue G, Maeda N, Suzuki K: Resurfacing of skin defects of the hand using the arterialised venous flap. Brit I Plast Surg 43:135, 1990 Taylor GI, Townsend P: Composite free flap and tendon transfer: An anatomical study and a clinical technique. Brit J Plast Surg 32:170, 1979
ADDITIONAL REFERENCES Inada Y, Fukui A, Tamai S, etai: An experimental study of the venous flap: Investigation of the recipient vein. J Reconstr Microsurg 6:123, 1990 Inoue G, Maeda N. Arterialized venous flap coverage for skin defects of the hand or foot. I Reconstr Microsurg 4:259, 1988 Rose EH: Small flap coverage of hand and digit defects. Clin Plast Surg 16:427, 1989 343
