Federico Inigo and Carlos Gargollo
SECONDARY COVERAGE OF THE HAND USING A DORSALIS PEDIS
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
PLUS FIRST WEB SPACE FREE FLAP ABSTRACT Traditionally, severe degloving injuries of the hand have been treated with random abdominal or pedicled groin flaps, which offer good cutaneus coverage but do not provide sensibility. The authors present the results of the application of an extended dorsalis pedis plus first web space of the foot flap to resurface the hands of five male patients who had been treated originally with random abdominal or pedicled groin flaps. The reported flap has the advantage of providing the patient with up to three different nerve territories, aiding in a better functional use of the hand. Severe degloving injuries of the hand affect the function and work capacity of the patient. Traditionally, hands with this type of injury have been treated with random abdominal flaps or pedicled groin flaps. These flaps offer good cutaneus coverage but have the drawbacks of not providing sensibility to protect the hand from trauma and external agents, and of not providing the patient with sensory feedback for better use of the hand. Since Cobbett first transferred a free toe in 1969,' microsurgery has enhanced hand surgery. It offers an ample spectrum of applications in replantation,2 free toe transfers 34 and free neurosensory flaps.5-8 Many flaps have been designed to restore sensibility to the injured hand. The dorsalis pedis flap was first reported by O'Brien and Shanmugan in 1973.9 In 1976, Daniel and Terzis5 applied it as a free neurovascular flap to restore sensibility to the hand of a worker. In 1975, Gilbert10 described a free neurovascular flap from the first web space of the foot, and achieved an average two-point discrimination of 11.3 mm with it. Since his publication, similar results have been reported by different authors. 67 The purpose of this communication is to present our experience in the management of traumatized hands originally treated with pedicled, noninnervated flaps, using a combination of dorsalis pedis and first web space flaps. This combination has the advantage of providing three different territories of innervation.
PATIENTS AND METHODS Five male patients, between 18 and 26 years of age, who had suffered degloving injuries of their hands were admitted to our service. They had all been treated originally with either random abdominal or pedicled groin flaps and were unable to return to their work because of anesthesia in the areas covered by the flaps. Two worked in the plastics industry, two were textile workers, and the other a press operator. Follow-up was from 2 to 5 years. Two surgical teams worked simultaneously, one on the foot and one on the hand. After excision of the skin in the areas lacking sensibility, the size and shape of the foot flap were marked. Blood vessels in the hand were dissected and prepared for anastomosis. The stumps of the digital nerves or the sensory branches of the radial or ulnar nerves, were dissected and prepared for anastomosis to the nerves of the flap. Because the first web space flap gives the best sensibility,11 we tried to use this part of the flap for the structures that required greater sensibility in all patients. The flap was raised according to the technique previously described for the dorsalis pedis flap,12 with the difference that it was extended to include the skin of the first web space of the foot. The flap was transferred to the hand, maintaining the planned orientation of the nerve territories. The
Department of Plastic and Reconstructive Surgery, Dr. Manuel Gea Gonzalez General Hospital and National University of Mexico, Mexico City Reprint requests-. Dr. Inigo, Calzada de tlalpan 4800, Mexico D.F 14000, Mexico Accepted for publication June 17, 1992 Copyright © 1992 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
461
artery and veins were first anastomosed to the recipient vessels and, subsequently, neurorraphies were performed. The flap was sutured in place, leaving drains when necessary, and the hand was immobilized with a plaster splint for 2 weeks or until all skin wounds healed, and the patient could begin sensory reeducation and therapy.
RESULTS The five patients operated on achieved excellent sensory results in their flaps, with two-point discrimination from 6 to 25 mm. All patients returned to productive activities, four to their original jobs and the fifth to a job that required less dexterity. There were no complications at either the donor or the recipient sites. The average operating time was 7 hr for the microvascular transfer; three patients required a second operation. The other two patients required two operations after the transfer, to complete separation of the fingers, and to provide skeletal stability when necessary.
REPRESENTATIVE CASE REPORTS CASE 1. (Fig. 1) In June 1983, a 23-year-old male worker suffered a crush injury with loss of the distal phalanges of the four ulnar fingers and a degloving injury at the level of the MP joints of the same fingers. The initial treatment involved application of a random abdominal flap. The patient consulted us in March
462
NOVEMBER 1992
1984, with a mitten hand and anesthesia of the palmar surface. He underwent surgical transfer of a free neurovascular dorsalis pedis plus first web flap in April 1984. Anastomosis of the dorsalis pedis artery with the ulnar artery was terminolateral. The saphenous vein was anastomosed to a dorsal wrist vein. The nerve anastomoses included deep peroneal with the radial digital nerve of the long finger, plantar digital with the radial digital nerve of the index finger, and superficial peroneal with the radial digital nerve of the ring finger. Three months later, the patient had protective sensation in the flap. Six months later, second-web syndactyly was released and a fusion of the index PIP was performed. After nine months postoperatively, the third web was also separated. One year after the transfer, two-point discrimination in the index finger was 8 mm, and 12 mm in the other three fingers. The patient has returned to his original position at a plastics factory. CASE 2. (Fig. 2) A 21-year-old male suffered a degloving injury of his right hand with a roller press in April, 1985. The initial treatment was disarticulation of the thumb at the IP level and of the four ulnar digits through the middle phalanges. The thumb stump was covered with a random abdominal flap, and the four fingers with a pedicled groin flap. In August, 1985, he received a free neurovascular dorsalis pedis plus first web flap. The first web portion of the flap covered the thumb and the dorsalis pedis the fingers. After syndactyly separation and deepening of the first web of the hand in a second operation, this patient has two-point discrimination in the thumb of 8 mm and 14 mm in the fingers, and has regained full use of his hand.
Figure 1. Case 1. A 23-year-old male worker. A, Early postoperative photograph of the hand showing the dorsalis pedis plus first web space flap in place. Drawing shows the artery and nerve anastomoses. DPA = dorsalis pedis artery; UA = ulnar artery; SPN = superficial peroneal nerve; DPN = deep peroneal nerve; PDN = plantar digital nerve. (Figure continued on next page)
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 8, NUMBER 6
B
Figure I, cont. B, Eight years post flap transfer, 7 years post third web release. The fingers have good, sensitive skin coverage. C, The patient has good pinch and strength.
DISCUSSION
Degloving injuries of specialized body structures, such as the palmar surface of the hand, present the surgeon with a great problem. These patients must receive adequate cover of the fine structures of the hand with skin that has good-to-excellent sensibility, so they can resume their original activities. With the present availability of microvascular techniques, large degloving or crushing injuries can initially be treated with free flaps24 that provide cover and sensation. However, in some cases, it is not possible to manage injuries with this technique initially, because of a lack of microsurgical facilities, poor condition of the patient, or special characteristics of the wound (too large, contaminated, etc.).
We present a combination of two previously described flaps, the dorsalis pedis9 and the first web space,10 dissected as a single unit and oriented transversely in the recipient bed. This flap has a long neurovascular pedicle and well-known anatomic patterns; it has a superficial and deep venous system, and can be wide enough to cover the whole palmar surface of the hand. It can also give the patient the advantage of having up to three different nerve territories in the hand, thus aiding in better cortical representation of the involved fingers and better stereognosis. When dissecting the flap, it is important to preserve the three nerves that supply this area: the deep peroneal nerve that runs parallel to the dorsalis pedis artery and innervates the dorsal surface of the first web; the superficial peroneal nerve that runs lateral to the former over the superficial fascia and innervates 463
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
DORSALIS PEDIS PLUS FIRST WEB FLAP/INIGO, GARGOLLO
NOVEMBER 1992
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 8, NUMBER 6
B
Figure 2. Case 2. A 21-year-old male. A, Postoperative photograph. The drawing shows the nerve anastomosis. PDN = plantar digital nerve; DPN = deep peroneal nerve; SPN = superficial peroneal nerve. B, Seven year postoperative photograph shows fine pinch and a useful hand.
the dorsum of the foot; the plantar digital nerve that innervates the plantar aspect of the first web and the lateral surface of the first and second toes (Fig. 3). In all patients, two-point discrimination was better at the recipient site than at the donor, because of better employment of the cutaneous receptors, as has been reported in other series.61113 The combined flap provides excellent cutaneous coverage of the hand. Improvement in skin quality and sensibility make the high morbidity of the donor site, especially the dorsalis pedis region, a worthwhile risk. In this series, we had no short-term complications at the donor sites. On follow-up, one patient complained 464
of cold intolerance and another had pain when he used hard shoes. Since all five patients are happy with their results, these minor complications do not constitute major concerns. CONCLUSION The use of an extended dorsalis pedis free neurovascular flap, to resurface hands treated initially with pedicled flaps, is a safe and reliable way of restoring good sensibility in separate nerve territories, with adequate skin cover and little bulk.
DORSALIS PEDIS PLUS FIRST WEB FLAP/INIGO, GARGOLLO
REFERENCES
2. 3. 4. 5. 6.
7. DPN
PON
8. DPA
9.
10. SPN
11.
12. 13.
Figure 3. Case 3. The raised flap. I, II and III in the drawing mark the three different nerve territories. DPN = deep peroneal nerve; PDN = plantar digital nerve; DPA _= dorsalis pedis artery; V = saphenous vein; SPN = superficial peroneal nerve.
14.
Cobbett JR: Free digital transfer: Report of a case of transfer of a great toe to replace an amputated thumb. I Bone Joint Surg 51B:677, 1969 Buncke HI, Schulz WP: Experimental digital amputation and reimplantation. Plast Reconstr Surg 36:62, 1965 Buncke HI, Rose E: Free toe to fingertip neurovascular flaps. Plast Reconstr Surg 63:607, 1979 Foucher G, Merle M, Manend M, Michon ): Microsurgical free partial toe transfer in hand reconstruction: A report of 12 cases. Plast Reconstr Surg 65:616, 1980 Rollin K, Daniel R, Terzis J, Midgley R: Restoration of sensation to an anesthetic hand by a free neurovascular flap from the foot. Plast Reconstr Surg 57:275, 1976 Morrison W, O'Brien B, MacLeod A, Gilbert A: Neurovascular free flaps from the foot for innervation of the hand. J Hand Surg 3A:235, 1978 Daniel R, Terzis I, May J: Neurovascular free flaps. In Serah'n D, Buncke H (eds.) Microsurgical Composite Tissue Transplantation. St. Louis: CV Mosby, 1979 Urbaniak R: Microsurgery for Major Limb Reconstruction. St. Louis: CV Mosby, 1987 O'Brien B, Shanmugan N: Experimental transfer of composite free flaps with microvascular anastomosis. Aust N Z I Surg 43:140, 1973 Gilbert A, Morrison W, Tubiana R, etal.-. Transfer of sensitive free flap to the hand. Chirurgie 101:691, 1975 May JW, Chait L, Cohen B, O'Brien B: Free neurovascular flap from the first web of the foot in hand reconstruction. I Hand Surg 2A:387, 1977 Caffe H, Hoefflin S: The extended dorsalis pedis flap. Plast Reconstr Surg 64:807, 1979 Strauch B, Tsur H: Restoration of sensation to the hand by a free neurovascular flap from the first web space of the foot. Plast Reconstr Surg 62:361, 1978 Lister G, Scheker L: Emergency free flaps to the upper extremity I Hand Surg 13A:22, 1988
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
1.
ADDITIONAL REFERENCES Rose El, Buncke HF: Free transfer of a large sensory flap from the first web space and dorsum of the foot including the second toe for reconstruction of a mutilated hand. ) Hand Surg 6:196, 1981 Strauch B, Greenstein B: Neurovascular flaps to the hand. Hand Clin 1:327, 1985
465
SECONDARY COVERAGE OF THE HAND USING A DORSALIS PEDIS
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
PLUS FIRST WEB SPACE FREE FLAP ABSTRACT Traditionally, severe degloving injuries of the hand have been treated with random abdominal or pedicled groin flaps, which offer good cutaneus coverage but do not provide sensibility. The authors present the results of the application of an extended dorsalis pedis plus first web space of the foot flap to resurface the hands of five male patients who had been treated originally with random abdominal or pedicled groin flaps. The reported flap has the advantage of providing the patient with up to three different nerve territories, aiding in a better functional use of the hand. Severe degloving injuries of the hand affect the function and work capacity of the patient. Traditionally, hands with this type of injury have been treated with random abdominal flaps or pedicled groin flaps. These flaps offer good cutaneus coverage but have the drawbacks of not providing sensibility to protect the hand from trauma and external agents, and of not providing the patient with sensory feedback for better use of the hand. Since Cobbett first transferred a free toe in 1969,' microsurgery has enhanced hand surgery. It offers an ample spectrum of applications in replantation,2 free toe transfers 34 and free neurosensory flaps.5-8 Many flaps have been designed to restore sensibility to the injured hand. The dorsalis pedis flap was first reported by O'Brien and Shanmugan in 1973.9 In 1976, Daniel and Terzis5 applied it as a free neurovascular flap to restore sensibility to the hand of a worker. In 1975, Gilbert10 described a free neurovascular flap from the first web space of the foot, and achieved an average two-point discrimination of 11.3 mm with it. Since his publication, similar results have been reported by different authors. 67 The purpose of this communication is to present our experience in the management of traumatized hands originally treated with pedicled, noninnervated flaps, using a combination of dorsalis pedis and first web space flaps. This combination has the advantage of providing three different territories of innervation.
PATIENTS AND METHODS Five male patients, between 18 and 26 years of age, who had suffered degloving injuries of their hands were admitted to our service. They had all been treated originally with either random abdominal or pedicled groin flaps and were unable to return to their work because of anesthesia in the areas covered by the flaps. Two worked in the plastics industry, two were textile workers, and the other a press operator. Follow-up was from 2 to 5 years. Two surgical teams worked simultaneously, one on the foot and one on the hand. After excision of the skin in the areas lacking sensibility, the size and shape of the foot flap were marked. Blood vessels in the hand were dissected and prepared for anastomosis. The stumps of the digital nerves or the sensory branches of the radial or ulnar nerves, were dissected and prepared for anastomosis to the nerves of the flap. Because the first web space flap gives the best sensibility,11 we tried to use this part of the flap for the structures that required greater sensibility in all patients. The flap was raised according to the technique previously described for the dorsalis pedis flap,12 with the difference that it was extended to include the skin of the first web space of the foot. The flap was transferred to the hand, maintaining the planned orientation of the nerve territories. The
Department of Plastic and Reconstructive Surgery, Dr. Manuel Gea Gonzalez General Hospital and National University of Mexico, Mexico City Reprint requests-. Dr. Inigo, Calzada de tlalpan 4800, Mexico D.F 14000, Mexico Accepted for publication June 17, 1992 Copyright © 1992 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
461
artery and veins were first anastomosed to the recipient vessels and, subsequently, neurorraphies were performed. The flap was sutured in place, leaving drains when necessary, and the hand was immobilized with a plaster splint for 2 weeks or until all skin wounds healed, and the patient could begin sensory reeducation and therapy.
RESULTS The five patients operated on achieved excellent sensory results in their flaps, with two-point discrimination from 6 to 25 mm. All patients returned to productive activities, four to their original jobs and the fifth to a job that required less dexterity. There were no complications at either the donor or the recipient sites. The average operating time was 7 hr for the microvascular transfer; three patients required a second operation. The other two patients required two operations after the transfer, to complete separation of the fingers, and to provide skeletal stability when necessary.
REPRESENTATIVE CASE REPORTS CASE 1. (Fig. 1) In June 1983, a 23-year-old male worker suffered a crush injury with loss of the distal phalanges of the four ulnar fingers and a degloving injury at the level of the MP joints of the same fingers. The initial treatment involved application of a random abdominal flap. The patient consulted us in March
462
NOVEMBER 1992
1984, with a mitten hand and anesthesia of the palmar surface. He underwent surgical transfer of a free neurovascular dorsalis pedis plus first web flap in April 1984. Anastomosis of the dorsalis pedis artery with the ulnar artery was terminolateral. The saphenous vein was anastomosed to a dorsal wrist vein. The nerve anastomoses included deep peroneal with the radial digital nerve of the long finger, plantar digital with the radial digital nerve of the index finger, and superficial peroneal with the radial digital nerve of the ring finger. Three months later, the patient had protective sensation in the flap. Six months later, second-web syndactyly was released and a fusion of the index PIP was performed. After nine months postoperatively, the third web was also separated. One year after the transfer, two-point discrimination in the index finger was 8 mm, and 12 mm in the other three fingers. The patient has returned to his original position at a plastics factory. CASE 2. (Fig. 2) A 21-year-old male suffered a degloving injury of his right hand with a roller press in April, 1985. The initial treatment was disarticulation of the thumb at the IP level and of the four ulnar digits through the middle phalanges. The thumb stump was covered with a random abdominal flap, and the four fingers with a pedicled groin flap. In August, 1985, he received a free neurovascular dorsalis pedis plus first web flap. The first web portion of the flap covered the thumb and the dorsalis pedis the fingers. After syndactyly separation and deepening of the first web of the hand in a second operation, this patient has two-point discrimination in the thumb of 8 mm and 14 mm in the fingers, and has regained full use of his hand.
Figure 1. Case 1. A 23-year-old male worker. A, Early postoperative photograph of the hand showing the dorsalis pedis plus first web space flap in place. Drawing shows the artery and nerve anastomoses. DPA = dorsalis pedis artery; UA = ulnar artery; SPN = superficial peroneal nerve; DPN = deep peroneal nerve; PDN = plantar digital nerve. (Figure continued on next page)
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 8, NUMBER 6
B
Figure I, cont. B, Eight years post flap transfer, 7 years post third web release. The fingers have good, sensitive skin coverage. C, The patient has good pinch and strength.
DISCUSSION
Degloving injuries of specialized body structures, such as the palmar surface of the hand, present the surgeon with a great problem. These patients must receive adequate cover of the fine structures of the hand with skin that has good-to-excellent sensibility, so they can resume their original activities. With the present availability of microvascular techniques, large degloving or crushing injuries can initially be treated with free flaps24 that provide cover and sensation. However, in some cases, it is not possible to manage injuries with this technique initially, because of a lack of microsurgical facilities, poor condition of the patient, or special characteristics of the wound (too large, contaminated, etc.).
We present a combination of two previously described flaps, the dorsalis pedis9 and the first web space,10 dissected as a single unit and oriented transversely in the recipient bed. This flap has a long neurovascular pedicle and well-known anatomic patterns; it has a superficial and deep venous system, and can be wide enough to cover the whole palmar surface of the hand. It can also give the patient the advantage of having up to three different nerve territories in the hand, thus aiding in better cortical representation of the involved fingers and better stereognosis. When dissecting the flap, it is important to preserve the three nerves that supply this area: the deep peroneal nerve that runs parallel to the dorsalis pedis artery and innervates the dorsal surface of the first web; the superficial peroneal nerve that runs lateral to the former over the superficial fascia and innervates 463
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
DORSALIS PEDIS PLUS FIRST WEB FLAP/INIGO, GARGOLLO
NOVEMBER 1992
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 8, NUMBER 6
B
Figure 2. Case 2. A 21-year-old male. A, Postoperative photograph. The drawing shows the nerve anastomosis. PDN = plantar digital nerve; DPN = deep peroneal nerve; SPN = superficial peroneal nerve. B, Seven year postoperative photograph shows fine pinch and a useful hand.
the dorsum of the foot; the plantar digital nerve that innervates the plantar aspect of the first web and the lateral surface of the first and second toes (Fig. 3). In all patients, two-point discrimination was better at the recipient site than at the donor, because of better employment of the cutaneous receptors, as has been reported in other series.61113 The combined flap provides excellent cutaneous coverage of the hand. Improvement in skin quality and sensibility make the high morbidity of the donor site, especially the dorsalis pedis region, a worthwhile risk. In this series, we had no short-term complications at the donor sites. On follow-up, one patient complained 464
of cold intolerance and another had pain when he used hard shoes. Since all five patients are happy with their results, these minor complications do not constitute major concerns. CONCLUSION The use of an extended dorsalis pedis free neurovascular flap, to resurface hands treated initially with pedicled flaps, is a safe and reliable way of restoring good sensibility in separate nerve territories, with adequate skin cover and little bulk.
DORSALIS PEDIS PLUS FIRST WEB FLAP/INIGO, GARGOLLO
REFERENCES
2. 3. 4. 5. 6.
7. DPN
PON
8. DPA
9.
10. SPN
11.
12. 13.
Figure 3. Case 3. The raised flap. I, II and III in the drawing mark the three different nerve territories. DPN = deep peroneal nerve; PDN = plantar digital nerve; DPA _= dorsalis pedis artery; V = saphenous vein; SPN = superficial peroneal nerve.
14.
Cobbett JR: Free digital transfer: Report of a case of transfer of a great toe to replace an amputated thumb. I Bone Joint Surg 51B:677, 1969 Buncke HI, Schulz WP: Experimental digital amputation and reimplantation. Plast Reconstr Surg 36:62, 1965 Buncke HI, Rose E: Free toe to fingertip neurovascular flaps. Plast Reconstr Surg 63:607, 1979 Foucher G, Merle M, Manend M, Michon ): Microsurgical free partial toe transfer in hand reconstruction: A report of 12 cases. Plast Reconstr Surg 65:616, 1980 Rollin K, Daniel R, Terzis J, Midgley R: Restoration of sensation to an anesthetic hand by a free neurovascular flap from the foot. Plast Reconstr Surg 57:275, 1976 Morrison W, O'Brien B, MacLeod A, Gilbert A: Neurovascular free flaps from the foot for innervation of the hand. J Hand Surg 3A:235, 1978 Daniel R, Terzis I, May J: Neurovascular free flaps. In Serah'n D, Buncke H (eds.) Microsurgical Composite Tissue Transplantation. St. Louis: CV Mosby, 1979 Urbaniak R: Microsurgery for Major Limb Reconstruction. St. Louis: CV Mosby, 1987 O'Brien B, Shanmugan N: Experimental transfer of composite free flaps with microvascular anastomosis. Aust N Z I Surg 43:140, 1973 Gilbert A, Morrison W, Tubiana R, etal.-. Transfer of sensitive free flap to the hand. Chirurgie 101:691, 1975 May JW, Chait L, Cohen B, O'Brien B: Free neurovascular flap from the first web of the foot in hand reconstruction. I Hand Surg 2A:387, 1977 Caffe H, Hoefflin S: The extended dorsalis pedis flap. Plast Reconstr Surg 64:807, 1979 Strauch B, Tsur H: Restoration of sensation to the hand by a free neurovascular flap from the first web space of the foot. Plast Reconstr Surg 62:361, 1978 Lister G, Scheker L: Emergency free flaps to the upper extremity I Hand Surg 13A:22, 1988
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
1.
ADDITIONAL REFERENCES Rose El, Buncke HF: Free transfer of a large sensory flap from the first web space and dorsum of the foot including the second toe for reconstruction of a mutilated hand. ) Hand Surg 6:196, 1981 Strauch B, Greenstein B: Neurovascular flaps to the hand. Hand Clin 1:327, 1985
465
