September 24, 2014
11:03:23am
WSPC/135-HS
FA1
1497009
Hand Surgery, Vol. 19, No. 3 (2014) 469–474 © World Scientific Publishing Company DOI: 10.1142/S0218810414970090
THE HOLEVICH FLAP REVISITED: A COMPARISON WITH THE FOUCHER FLAP, CASE SERIES Jose Couceiro and Marcos Sanmartín
Hand Surg. 2014.19:469-474. Downloaded from www.worldscientific.com by MONASH UNIVERSITY on 02/03/15. For personal use only.
Hand Surgery Unit, Orthopaedics Department POVISA Hospital, Vigo, Spain Received 5 January 2014; Revised 17 February 2014; Accepted 18 February 2014; Published 26 August 2014 ABSTRACT The first dorsal metacarpal artery flap was initially described by Hilgenfeldt, it was designed as a racquet flap by Holevich and modified as an island flap by Foucher and Braun. The objective of the present is to compare the Holevich flap and the Foucher flap in terms of venous congestion and flap necrosis. From 2009 to 2013, ten first dorsal metacarpal artery flaps were performed at our hospital’s hand unit. Five of the flaps were Holevich type flaps and five of the flaps were Foucher flaps. There were seven men and three women. The mean age was 47 years for the Foucher flap group (17–67 years), and 48 years for the Holevich flap group (36–61 years). Strength, static two tips discrimination, ranges of motion, satisfaction, cold intolerance, pain, flap congestion and flap necrosis were recorded for both groups. Similar values of strength, pain, range of motion and two tips discrimination were found on both groups. There was a higher incidence of flap congestion and necrosis on the Foucher flap group (two thumbs underwent partial flap necrosis and two underwent venous congestion in three patients). There was also a higher incidence of cold intolerance in the Foucher group (two patients exhibited moderate cold intolerance and one exhibited a severe cold intolerance). A proper statistical analysis was not possible due to the size of the case series. In this small case series the Holevich exhibited less flap necrosis, less venous congestion, and less incidence of cold intolerance than the Foucher flap. Keywords: Thumb; Kite Flap; Foucher; Venous Congestion; Holevich.
INTRODUCTION
We have found however no articles comparing the reliability and complications of the Holevich and Foucher flaps in terms of necrosis and venous congestion. The aim of the present work is to describe the results of a series of patients treated with the Holevich flap. We also compared this group of patients in terms of flap necrosis and venous congestion to a control group treated with the Foucher flap. Our hypothesis was that the use of the Holevich flap resulted in less venous congestion and less percentage of flap necrosis than the Foucher flap.
Strategies for the reconstruction deep soft tissue defects of the thumb include the use of classical local flaps such as the Moberg flap and its variations for small defects. More extensive injuries require the use of regional or free flaps. The first dorsal metacarpal artery (FDMA) flap was initially described by Hilgenfeldt1; it was subsequently modified by Holevich,2 and it was popularised by Foucher and Braun3 as an island flap. Results for this flap have been extensively reported in the literature.
Correspondence to: Dr. Jose Couceiro, Hand Surgery Unit, Orthopaedics Department, POVISA Hospital, Calle Salamanca, 5, 36211, Vigo, Spain. Tel: (þ34) 6-76230437, Fax: (þ34) 9-8641-3144, E-mail: [email protected] 469
September 24, 2014
470
11:03:24am
WSPC/135-HS
FA1
1497009
J. Couceiro & M. Sanmartín
MATERIAL AND METHODS
graft, the donor area for the skin bridge was closed primarily a small skin graft at the pivot point was needed in two cases. For the Foucher flaps the original technique as described by Foucher and Braun3 was used. The first dorsal intermetacarpal artery was located with a Doppler ultrasound and the artery’s path was marked with a needle. The desired flap is drawn on the dorsum of the index finger. The dissection is started ulnarly at the border of the flap. The artery is exposed through a straight incision. The aponeurosis with the perivascular fat and the pedicle is raised, two superficial veins are dissected and raised with the pedicle. The radial nerve branches are included in the flap. The radial edge of the flap is raised, part of the radial extensor sagittal band is included in the flap if needed and the flap is transfered. The donor site was grafted with a split thickness skin graft, and the incision for the pedicle dissection was closed primarily.
From 2009 to 2013, ten first dorsal metacarpal artery flaps were performed at our hospital’s hand unit. All of the surgeries were done by two hand fellowship trained orthopedic hand surgeons. Five of the flaps were Holevich type flaps and five of the flaps were Foucher flaps. There were seven men and three women. The mean age was 47 years for the Foucher flap group (17–67 years), and 48 years for the Holevich flap group (36–61 years).
Hand Surg. 2014.19:469-474. Downloaded from www.worldscientific.com by MONASH UNIVERSITY on 02/03/15. For personal use only.
Surgical Technique For the Holevich flaps the first dorsal intermetacarpal artery was localised with Doppler ultrasound and the artery’s path was marked with a needle. An 0.5 cm strip of skin was marked on either side of this path. The desired flap was drawn on the dorsum of the index finger (Fig. 1). Dissection was started ulnarly and progressed radially, part of the radial extensor sagittal band was included in the flap if needed. For the skin bridge, the underlying dissection was taken to the metacarpal shaft, the fascia which contains the artery was dissected with the flap from the underlying muscular plane. The skin bridge between the flap and the defect was fully opened; and the flap was transfered. The donor site was grafted with a split thickness skin
(A)
(D)
Two Tips Discrimination Static two tips discrimination was measured with a touch test two point discriminator (North coast medical, Ca, USA). Measures were taken on each visit both on the operated thumb and on the contralateral side.
(B)
(C)
(E)
(F)
Fig. 1 (A) and (B) Volar ulnar defect caused by a chainsaw, the vertical needle track marks the course of the first dorsal intermetacarpal artery. (C) The flap is designed. (D) The dissection is started radially. (E) The flap is raised and the skin bridge is incised. (F) Immediate post-operative picture.
September 24, 2014
11:03:24am
WSPC/135-HS
FA1
1497009
Comparison of the Holevich and Foucher Flaps
Range of Motion
Hand Surg. 2014.19:469-474. Downloaded from www.worldscientific.com by MONASH UNIVERSITY on 02/03/15. For personal use only.
The range of motion was measured with an exacta finger goniometer (North coast medical, Ca, USA). Both at the thumb and the index finger of the operated hand.
471
The mean key grip strength on the affected side was 7.2 kg, 63% of the mean strength of the unaffected side, 11.4 kg. The mean grip pinch was 6.6 kg on the affected side, 66% of the mean grip pinch on the contralateral unaffected side, 10 kg.
Strength
Two Tips Discrimination
Grip measurements were performed with a Jamar dynamometer (Baseline evaluation instruments, NY, USA) both at the affected and contralateral hands. Key and pinch grips were measured with a hydraulic pinch gauge (baseline evaluation instruments, NY, USA).
Mean static two tips discrimination was 10 mm (8–15 mm).
Range of Motion
Patient satisfaction was qualified by the patient as: completely unsatisfied, unsatisfied, partly satisfied, or completely satisfied.
Only one of the patient exhibited a diminished range of motion at the thumb, lacking 20 of flexion at the interphalangeal joint. The rest had values comparable to the contralateral thumb. All of the patients had some stiffness of the index finger at the early post-operatory phase, this recovered without the need for further surgical procedures.
Cold Intolerance
Return to Work
Intolerance to cold was evaluated with the cold severity scale (CSS) as described by McCabe et al.4
One of the patients (number one) returned to work at two months and was lost to follow-up. Two of the patients were a carpenter and a clerk at hardware store (numbers three and four); they returned to their previous work in three months. The two remaining patients were on disability previously to the surgery and they remained in disability after the procedure.
Patient Satisfaction
Pain Pain was evaluated with the visual analog pain scale from 1 (no pain) to 10 (excruciating).
Venous Congestion and Flap Necrosis Venous congestion was qualified as none, slight, moderate or severe. Flap necrosis was expressed as a percentage (0 to 100%).
Cortical Reorientation No cortical reorientation was observed in two of the patients (three and four).
Satisfaction RESULTS Holevich Flaps Our results are summarised in Table 1.
Two of the patients were partly satisfied, the three remaining were completely satisfied with the procedure.
Pain
Follow-Up
The mean visual analog scale value was 2.7 (1–6).
The mean follow-up was 5.4 months (3–9 months). One of the patients (number one) was a sailor and he was lost to followup at three months because of his work.
Cold Intolerance None of the patients exhibited cold intolerance the mean CSS value was 0.
Strength The mean grip strength on the affected hand was 34 kg, 72% of the mean strength of the unaffected hand which was 47 kg.
Foucher Flap Results Our results are summarised in Table 2.
Volar 50 Volar 44
F F
Crush Glass
1:5 2 1 1:5 11 10
Volar 67 M Osteomielitis 1 2 7 Volar 17 F Bum 1:5 2:5 9 Volar 55 M Saw 21 N/A Full Full N/A
ROM Thumb
6 6
N/A 6 6
Foucher Flap Results.
7.5 5
N/A 7 7
Table 2
Full Partial
Full Partial Full
0 0
0 0 0
0 0
0 0 0 9 11
N/A 12 8 10 9
N/A 4 6 12.5 12
N/A 10 11 40 32
N/A 26 38 42 50
N/A 50 46 0 0
one 13/11/2013 two 13/11/2013
N/A one 06/03/2013 0 six 18/09/2013 0 one 25/09/2013
16/05/2013 30/08/2013
22/11/2012 13/12/2012 02/04/2013
full full N/A Severe 0
0 0 Moderate
25 0
15 0 0
Partial Dissatisfied
Full Full Partial
1.5 1
2 2 N/A
3 2.6
1.5 3 N/A
3 2
5.5 4.5 N/A
7 7.6
5.5 6.5 N/A
40 N/A
28 14 N/A
10 12
22 38 N/A
12 5
0 8 N/A
5 14/02/2014 6 05/02/2014
1 07/02/2014 5 07/02/2014
12/07/2012 30/09/2013
05/11/2009 11/03/2010 26/04/2011
Key Grip Grip Grip Pinch Pinch Contra Key Contra Front Contra ROM Congestion Necrosis Index (%) (%) Satisfaction (kg) (kg) (kg) (kg) (kg) (kg) CSS VAS Last FU Surgery Date
Full Full Lack 15 lPJ full
8 10
3 3:5 2 2:5
Defect Size 2PD (cm) (mm)
N/A 15 8
N/A 2 2:5 23
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1 2 3 14/02/2011 4 5
Patient
Volar 51 Volar ulnar 61
4 5
M Saw M Blunt trauma M Chainsaw, tree fall M Saw M Saw
Surgery Date
WSPC/135-HS
Defect Site Age Sex Mechanism
Volar radial 49 Dorsal 45 Volar 36
1 2 3
Last FU
11:03:27am
Key Grip Grip Grip Pinch 2PD Pinch Contra Key Contra Front Contra Defect 2PD Contralat Congestion Necrosis (%) (%) Satisfaction (kg) (kg) (kg) (kg) (kg) (kg) CSS VAS Patient Defect Site Age Sex Mechanism Size (cm) (mm) (mm)
Holevich Flap Results.
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Table 1
Hand Surg. 2014.19:469-474. Downloaded from www.worldscientific.com by MONASH UNIVERSITY on 02/03/15. For personal use only. September 24, 2014
FA1
J. Couceiro & M. Sanmartín
September 24, 2014
11:03:27am
WSPC/135-HS
FA1
1497009
Comparison of the Holevich and Foucher Flaps
Follow-Up
Pain
The mean follow-up was 25 months (3–52 months), patient three was lost to follow-up at three months.
The mean visual analog scale value was 4 (1–6).
473
Cold Intolerance Strength
Hand Surg. 2014.19:469-474. Downloaded from www.worldscientific.com by MONASH UNIVERSITY on 02/03/15. For personal use only.
The mean grip strength on the affected hand was 27 kg, 76% of the mean strength of the unaffected hand which was 20.5 kg. The mean key grip strength on the affected side was 3.7 kg, 56% of the mean strength of the unaffected side, 6.7 kg. The mean grip pinch was 1.6 kg on the affected side, 64% of the mean grip pinch on the contralateral unaffected side, 2.5 kg.
Two Tips Discrimination Mean static two tips discrimination was 9 mm (mm).
Range of Motion One of the patients (number five) lacked 15 of flexion at the interphalangeal joint of the thumb. The rest of the patients exhibited a range of motion at the affected thumb that was comparable to the unaffected side. All of the patients had a range of motion at the donor index finger which was comparable to the contralateral side.
Return to Work The mean return to work time was six months (3–7 months). One of the patients (patient one) was retired at the time of surgery, another patient (number five) was on disability. One of the patients was a housewife (number two), she returned to her regular activities in seven months. The two remaining patients were manual workers and they returned to their previous positions at three and seven months respectively.
Cortical Reorientation No cortical reorientation was seen in two of the patients (two and five).
Satisfaction One of the patients was dissatisfied with the result of her flap, two were partly satisfied, and two were completely satisfied with the result.
Two of the patients (two and five) exhibited a moderate cold intolerance, one of the patients (number four) exhibited a severe cold intolerance. The mean CSS score was 6.
Necrosis and Venous Congestion Two of the Foucher flaps exhibited partial necrosis, one had a moderate postoperative congestion that resolved without the need for further surgery, and one had a severe congestion that led to a partial necrosis of the flap. A second intervention was needed to shorten the fingertip on this latter case None of the Holevich flaps exhibited any areas of necrosis or venous congestion at any stage.
DISCUSSION In his 1963 article Holevich2 states that he started using the first dorsal metacarpal artery flap as an island flap. He begun performing the racquet flap modification in an effort to improve sensitivity on the anteromedial border following a thumb reconstruction by the Nicoladoni method. He reports no problems with flap necrosis or venous return. We have found few reports that address venous congestion on FDMA flaps, El-Khatib5 reported no flap necrosis, but venous congestion in all of the five flaps in his case series. Zhang et al.6 reported partial flap necrosis in two out of 42 thumbs; they also report experiencing some degree of venous congestion that did not require surgery, but they did not specify how many flaps or how severe the degree of congestion was. Our work suggests a higher degree of venous congestion, two of our five cases of Foucher flap became congestive postoperatively; another two flaps exhibited partial necrosis. The Holevich flaps did not exhibit venous congestion or necrosis, and we think this difference is caused by the raquet design providing a greater venous outflow, and also by the absence of a subcutaneous tunnel that could compress the pedicle. The range of motion, strength and pain results were similar in the Foucher and the Holevich flap groups. Satisfaction appeared to be slightly lower in the Foucher group, this group contained more female patients than the Holevich flap group;
September 24, 2014
Hand Surg. 2014.19:469-474. Downloaded from www.worldscientific.com by MONASH UNIVERSITY on 02/03/15. For personal use only.
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these patients were more concerned with aesthetics than their male counterparts. It is also remarkable that in our small case series we have found no cold intolerance for the Holevich flaps measured with the cold intolerance severity scale, which compares favorably with the literature which reports a 20% of cold intolerance for the Foucher island flap.7 There were two patients with moderate cold intolerance and one patient with a severe cold intolerance in the Foucher flap group. We believe that since the Holevich flap is racquet shaped, it transfers more nerve branches to the thumb allowing for a better temperature control. The main limitations to our work were the small number of cases, not allowing for an statistical analysis; and the lack of randomisation. In conclusion in this comparative study we found a higher incidence of venous congestion, a higher percentage of flap necrosis and a higher incidence of cold intolerance for the Foucher flap when compared to the Holevich flap. Definitive superiority of one of the flaps cannot be completely ascertained due to the size and nature of the study.
References 1. Hilgenfeldt O, Operativer Daumenersatz, Enkeverslag, Stuttgart, 1950. 2. Holevich J, A new method of restoring sensibility to the thumb, Bone Joint Surg Br 45B:496–502, 1963. 3. Foucher G, Braun JB, A new island flap transfer from the dorsum of the index to the thumb, Plast Reconstr Surg 63:344–349, 1979. 4. Craigen M, Kleinert JM, Crain GM, McCabe SJ, Patient and injury characteristics in the development of cold sensitivity of the hand: A prospective chort study, J Hand Surg Am 24(1):8–15, 1999. 5. El-Khatib HA, Clinical experiences with the extended first dorsal metacarpal artery island flap for thumb reconstruction, J Hand Surg Am 23A:647–652, 1998. 6. Zhang X, Shao X, Ren C, Zhang Z, Wen S, Sun J, Reconstruction of thumb pulp defects using a modified kite flap, J Hand Surg Am 36(10):1597– 1603, 2011. 7. Tränkle M, Sauerbier M, Heitmann C, Germann G, Restoration of thumb sensibility with the innervated first dorsal metacarpal artery island flap, J Hand Surg Am 28(5):758–766, 2003.
11:03:23am
WSPC/135-HS
FA1
1497009
Hand Surgery, Vol. 19, No. 3 (2014) 469–474 © World Scientific Publishing Company DOI: 10.1142/S0218810414970090
THE HOLEVICH FLAP REVISITED: A COMPARISON WITH THE FOUCHER FLAP, CASE SERIES Jose Couceiro and Marcos Sanmartín
Hand Surg. 2014.19:469-474. Downloaded from www.worldscientific.com by MONASH UNIVERSITY on 02/03/15. For personal use only.
Hand Surgery Unit, Orthopaedics Department POVISA Hospital, Vigo, Spain Received 5 January 2014; Revised 17 February 2014; Accepted 18 February 2014; Published 26 August 2014 ABSTRACT The first dorsal metacarpal artery flap was initially described by Hilgenfeldt, it was designed as a racquet flap by Holevich and modified as an island flap by Foucher and Braun. The objective of the present is to compare the Holevich flap and the Foucher flap in terms of venous congestion and flap necrosis. From 2009 to 2013, ten first dorsal metacarpal artery flaps were performed at our hospital’s hand unit. Five of the flaps were Holevich type flaps and five of the flaps were Foucher flaps. There were seven men and three women. The mean age was 47 years for the Foucher flap group (17–67 years), and 48 years for the Holevich flap group (36–61 years). Strength, static two tips discrimination, ranges of motion, satisfaction, cold intolerance, pain, flap congestion and flap necrosis were recorded for both groups. Similar values of strength, pain, range of motion and two tips discrimination were found on both groups. There was a higher incidence of flap congestion and necrosis on the Foucher flap group (two thumbs underwent partial flap necrosis and two underwent venous congestion in three patients). There was also a higher incidence of cold intolerance in the Foucher group (two patients exhibited moderate cold intolerance and one exhibited a severe cold intolerance). A proper statistical analysis was not possible due to the size of the case series. In this small case series the Holevich exhibited less flap necrosis, less venous congestion, and less incidence of cold intolerance than the Foucher flap. Keywords: Thumb; Kite Flap; Foucher; Venous Congestion; Holevich.
INTRODUCTION
We have found however no articles comparing the reliability and complications of the Holevich and Foucher flaps in terms of necrosis and venous congestion. The aim of the present work is to describe the results of a series of patients treated with the Holevich flap. We also compared this group of patients in terms of flap necrosis and venous congestion to a control group treated with the Foucher flap. Our hypothesis was that the use of the Holevich flap resulted in less venous congestion and less percentage of flap necrosis than the Foucher flap.
Strategies for the reconstruction deep soft tissue defects of the thumb include the use of classical local flaps such as the Moberg flap and its variations for small defects. More extensive injuries require the use of regional or free flaps. The first dorsal metacarpal artery (FDMA) flap was initially described by Hilgenfeldt1; it was subsequently modified by Holevich,2 and it was popularised by Foucher and Braun3 as an island flap. Results for this flap have been extensively reported in the literature.
Correspondence to: Dr. Jose Couceiro, Hand Surgery Unit, Orthopaedics Department, POVISA Hospital, Calle Salamanca, 5, 36211, Vigo, Spain. Tel: (þ34) 6-76230437, Fax: (þ34) 9-8641-3144, E-mail: [email protected] 469
September 24, 2014
470
11:03:24am
WSPC/135-HS
FA1
1497009
J. Couceiro & M. Sanmartín
MATERIAL AND METHODS
graft, the donor area for the skin bridge was closed primarily a small skin graft at the pivot point was needed in two cases. For the Foucher flaps the original technique as described by Foucher and Braun3 was used. The first dorsal intermetacarpal artery was located with a Doppler ultrasound and the artery’s path was marked with a needle. The desired flap is drawn on the dorsum of the index finger. The dissection is started ulnarly at the border of the flap. The artery is exposed through a straight incision. The aponeurosis with the perivascular fat and the pedicle is raised, two superficial veins are dissected and raised with the pedicle. The radial nerve branches are included in the flap. The radial edge of the flap is raised, part of the radial extensor sagittal band is included in the flap if needed and the flap is transfered. The donor site was grafted with a split thickness skin graft, and the incision for the pedicle dissection was closed primarily.
From 2009 to 2013, ten first dorsal metacarpal artery flaps were performed at our hospital’s hand unit. All of the surgeries were done by two hand fellowship trained orthopedic hand surgeons. Five of the flaps were Holevich type flaps and five of the flaps were Foucher flaps. There were seven men and three women. The mean age was 47 years for the Foucher flap group (17–67 years), and 48 years for the Holevich flap group (36–61 years).
Hand Surg. 2014.19:469-474. Downloaded from www.worldscientific.com by MONASH UNIVERSITY on 02/03/15. For personal use only.
Surgical Technique For the Holevich flaps the first dorsal intermetacarpal artery was localised with Doppler ultrasound and the artery’s path was marked with a needle. An 0.5 cm strip of skin was marked on either side of this path. The desired flap was drawn on the dorsum of the index finger (Fig. 1). Dissection was started ulnarly and progressed radially, part of the radial extensor sagittal band was included in the flap if needed. For the skin bridge, the underlying dissection was taken to the metacarpal shaft, the fascia which contains the artery was dissected with the flap from the underlying muscular plane. The skin bridge between the flap and the defect was fully opened; and the flap was transfered. The donor site was grafted with a split thickness skin
(A)
(D)
Two Tips Discrimination Static two tips discrimination was measured with a touch test two point discriminator (North coast medical, Ca, USA). Measures were taken on each visit both on the operated thumb and on the contralateral side.
(B)
(C)
(E)
(F)
Fig. 1 (A) and (B) Volar ulnar defect caused by a chainsaw, the vertical needle track marks the course of the first dorsal intermetacarpal artery. (C) The flap is designed. (D) The dissection is started radially. (E) The flap is raised and the skin bridge is incised. (F) Immediate post-operative picture.
September 24, 2014
11:03:24am
WSPC/135-HS
FA1
1497009
Comparison of the Holevich and Foucher Flaps
Range of Motion
Hand Surg. 2014.19:469-474. Downloaded from www.worldscientific.com by MONASH UNIVERSITY on 02/03/15. For personal use only.
The range of motion was measured with an exacta finger goniometer (North coast medical, Ca, USA). Both at the thumb and the index finger of the operated hand.
471
The mean key grip strength on the affected side was 7.2 kg, 63% of the mean strength of the unaffected side, 11.4 kg. The mean grip pinch was 6.6 kg on the affected side, 66% of the mean grip pinch on the contralateral unaffected side, 10 kg.
Strength
Two Tips Discrimination
Grip measurements were performed with a Jamar dynamometer (Baseline evaluation instruments, NY, USA) both at the affected and contralateral hands. Key and pinch grips were measured with a hydraulic pinch gauge (baseline evaluation instruments, NY, USA).
Mean static two tips discrimination was 10 mm (8–15 mm).
Range of Motion
Patient satisfaction was qualified by the patient as: completely unsatisfied, unsatisfied, partly satisfied, or completely satisfied.
Only one of the patient exhibited a diminished range of motion at the thumb, lacking 20 of flexion at the interphalangeal joint. The rest had values comparable to the contralateral thumb. All of the patients had some stiffness of the index finger at the early post-operatory phase, this recovered without the need for further surgical procedures.
Cold Intolerance
Return to Work
Intolerance to cold was evaluated with the cold severity scale (CSS) as described by McCabe et al.4
One of the patients (number one) returned to work at two months and was lost to follow-up. Two of the patients were a carpenter and a clerk at hardware store (numbers three and four); they returned to their previous work in three months. The two remaining patients were on disability previously to the surgery and they remained in disability after the procedure.
Patient Satisfaction
Pain Pain was evaluated with the visual analog pain scale from 1 (no pain) to 10 (excruciating).
Venous Congestion and Flap Necrosis Venous congestion was qualified as none, slight, moderate or severe. Flap necrosis was expressed as a percentage (0 to 100%).
Cortical Reorientation No cortical reorientation was observed in two of the patients (three and four).
Satisfaction RESULTS Holevich Flaps Our results are summarised in Table 1.
Two of the patients were partly satisfied, the three remaining were completely satisfied with the procedure.
Pain
Follow-Up
The mean visual analog scale value was 2.7 (1–6).
The mean follow-up was 5.4 months (3–9 months). One of the patients (number one) was a sailor and he was lost to followup at three months because of his work.
Cold Intolerance None of the patients exhibited cold intolerance the mean CSS value was 0.
Strength The mean grip strength on the affected hand was 34 kg, 72% of the mean strength of the unaffected hand which was 47 kg.
Foucher Flap Results Our results are summarised in Table 2.
Volar 50 Volar 44
F F
Crush Glass
1:5 2 1 1:5 11 10
Volar 67 M Osteomielitis 1 2 7 Volar 17 F Bum 1:5 2:5 9 Volar 55 M Saw 21 N/A Full Full N/A
ROM Thumb
6 6
N/A 6 6
Foucher Flap Results.
7.5 5
N/A 7 7
Table 2
Full Partial
Full Partial Full
0 0
0 0 0
0 0
0 0 0 9 11
N/A 12 8 10 9
N/A 4 6 12.5 12
N/A 10 11 40 32
N/A 26 38 42 50
N/A 50 46 0 0
one 13/11/2013 two 13/11/2013
N/A one 06/03/2013 0 six 18/09/2013 0 one 25/09/2013
16/05/2013 30/08/2013
22/11/2012 13/12/2012 02/04/2013
full full N/A Severe 0
0 0 Moderate
25 0
15 0 0
Partial Dissatisfied
Full Full Partial
1.5 1
2 2 N/A
3 2.6
1.5 3 N/A
3 2
5.5 4.5 N/A
7 7.6
5.5 6.5 N/A
40 N/A
28 14 N/A
10 12
22 38 N/A
12 5
0 8 N/A
5 14/02/2014 6 05/02/2014
1 07/02/2014 5 07/02/2014
12/07/2012 30/09/2013
05/11/2009 11/03/2010 26/04/2011
Key Grip Grip Grip Pinch Pinch Contra Key Contra Front Contra ROM Congestion Necrosis Index (%) (%) Satisfaction (kg) (kg) (kg) (kg) (kg) (kg) CSS VAS Last FU Surgery Date
Full Full Lack 15 lPJ full
8 10
3 3:5 2 2:5
Defect Size 2PD (cm) (mm)
N/A 15 8
N/A 2 2:5 23
1497009
1 2 3 14/02/2011 4 5
Patient
Volar 51 Volar ulnar 61
4 5
M Saw M Blunt trauma M Chainsaw, tree fall M Saw M Saw
Surgery Date
WSPC/135-HS
Defect Site Age Sex Mechanism
Volar radial 49 Dorsal 45 Volar 36
1 2 3
Last FU
11:03:27am
Key Grip Grip Grip Pinch 2PD Pinch Contra Key Contra Front Contra Defect 2PD Contralat Congestion Necrosis (%) (%) Satisfaction (kg) (kg) (kg) (kg) (kg) (kg) CSS VAS Patient Defect Site Age Sex Mechanism Size (cm) (mm) (mm)
Holevich Flap Results.
472
Table 1
Hand Surg. 2014.19:469-474. Downloaded from www.worldscientific.com by MONASH UNIVERSITY on 02/03/15. For personal use only. September 24, 2014
FA1
J. Couceiro & M. Sanmartín
September 24, 2014
11:03:27am
WSPC/135-HS
FA1
1497009
Comparison of the Holevich and Foucher Flaps
Follow-Up
Pain
The mean follow-up was 25 months (3–52 months), patient three was lost to follow-up at three months.
The mean visual analog scale value was 4 (1–6).
473
Cold Intolerance Strength
Hand Surg. 2014.19:469-474. Downloaded from www.worldscientific.com by MONASH UNIVERSITY on 02/03/15. For personal use only.
The mean grip strength on the affected hand was 27 kg, 76% of the mean strength of the unaffected hand which was 20.5 kg. The mean key grip strength on the affected side was 3.7 kg, 56% of the mean strength of the unaffected side, 6.7 kg. The mean grip pinch was 1.6 kg on the affected side, 64% of the mean grip pinch on the contralateral unaffected side, 2.5 kg.
Two Tips Discrimination Mean static two tips discrimination was 9 mm (mm).
Range of Motion One of the patients (number five) lacked 15 of flexion at the interphalangeal joint of the thumb. The rest of the patients exhibited a range of motion at the affected thumb that was comparable to the unaffected side. All of the patients had a range of motion at the donor index finger which was comparable to the contralateral side.
Return to Work The mean return to work time was six months (3–7 months). One of the patients (patient one) was retired at the time of surgery, another patient (number five) was on disability. One of the patients was a housewife (number two), she returned to her regular activities in seven months. The two remaining patients were manual workers and they returned to their previous positions at three and seven months respectively.
Cortical Reorientation No cortical reorientation was seen in two of the patients (two and five).
Satisfaction One of the patients was dissatisfied with the result of her flap, two were partly satisfied, and two were completely satisfied with the result.
Two of the patients (two and five) exhibited a moderate cold intolerance, one of the patients (number four) exhibited a severe cold intolerance. The mean CSS score was 6.
Necrosis and Venous Congestion Two of the Foucher flaps exhibited partial necrosis, one had a moderate postoperative congestion that resolved without the need for further surgery, and one had a severe congestion that led to a partial necrosis of the flap. A second intervention was needed to shorten the fingertip on this latter case None of the Holevich flaps exhibited any areas of necrosis or venous congestion at any stage.
DISCUSSION In his 1963 article Holevich2 states that he started using the first dorsal metacarpal artery flap as an island flap. He begun performing the racquet flap modification in an effort to improve sensitivity on the anteromedial border following a thumb reconstruction by the Nicoladoni method. He reports no problems with flap necrosis or venous return. We have found few reports that address venous congestion on FDMA flaps, El-Khatib5 reported no flap necrosis, but venous congestion in all of the five flaps in his case series. Zhang et al.6 reported partial flap necrosis in two out of 42 thumbs; they also report experiencing some degree of venous congestion that did not require surgery, but they did not specify how many flaps or how severe the degree of congestion was. Our work suggests a higher degree of venous congestion, two of our five cases of Foucher flap became congestive postoperatively; another two flaps exhibited partial necrosis. The Holevich flaps did not exhibit venous congestion or necrosis, and we think this difference is caused by the raquet design providing a greater venous outflow, and also by the absence of a subcutaneous tunnel that could compress the pedicle. The range of motion, strength and pain results were similar in the Foucher and the Holevich flap groups. Satisfaction appeared to be slightly lower in the Foucher group, this group contained more female patients than the Holevich flap group;
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these patients were more concerned with aesthetics than their male counterparts. It is also remarkable that in our small case series we have found no cold intolerance for the Holevich flaps measured with the cold intolerance severity scale, which compares favorably with the literature which reports a 20% of cold intolerance for the Foucher island flap.7 There were two patients with moderate cold intolerance and one patient with a severe cold intolerance in the Foucher flap group. We believe that since the Holevich flap is racquet shaped, it transfers more nerve branches to the thumb allowing for a better temperature control. The main limitations to our work were the small number of cases, not allowing for an statistical analysis; and the lack of randomisation. In conclusion in this comparative study we found a higher incidence of venous congestion, a higher percentage of flap necrosis and a higher incidence of cold intolerance for the Foucher flap when compared to the Holevich flap. Definitive superiority of one of the flaps cannot be completely ascertained due to the size and nature of the study.
References 1. Hilgenfeldt O, Operativer Daumenersatz, Enkeverslag, Stuttgart, 1950. 2. Holevich J, A new method of restoring sensibility to the thumb, Bone Joint Surg Br 45B:496–502, 1963. 3. Foucher G, Braun JB, A new island flap transfer from the dorsum of the index to the thumb, Plast Reconstr Surg 63:344–349, 1979. 4. Craigen M, Kleinert JM, Crain GM, McCabe SJ, Patient and injury characteristics in the development of cold sensitivity of the hand: A prospective chort study, J Hand Surg Am 24(1):8–15, 1999. 5. El-Khatib HA, Clinical experiences with the extended first dorsal metacarpal artery island flap for thumb reconstruction, J Hand Surg Am 23A:647–652, 1998. 6. Zhang X, Shao X, Ren C, Zhang Z, Wen S, Sun J, Reconstruction of thumb pulp defects using a modified kite flap, J Hand Surg Am 36(10):1597– 1603, 2011. 7. Tränkle M, Sauerbier M, Heitmann C, Germann G, Restoration of thumb sensibility with the innervated first dorsal metacarpal artery island flap, J Hand Surg Am 28(5):758–766, 2003.
