Immediate reconstruction

Experience accumulated in dealing with emergency free flaps has logically progressed into single-stage reconstruction in cases in which bone, tendon, and soft tissue have been lost. Dorsal hand injuries commonly involve the loss of all three types of tissue and provide a good example of the challenges of immediate reconstruction. As mentioned previously, in these cases, one of the surfaces is intact and the patient can have a much better result than in replantation if managed in the appropriate manner. The skin on the dorsum of the hand requires the ability to stretch by 10% to 22% to make a full fist. A skin graft generally does not provide enough elasticity for the patient to make a full fist. For that reason, it is important to replace the dorsum of the hand with a flap rather than a skin graft. Performing tendon repairs along with emergency free flap coverage provides the opportunity to pass tendons singly through tunnels created in the flap's subcutaneous tissue. Unlike skin grafts, which do not provide enough cushioning and break down easily, and muscle flaps, which are bulky and can tear more easily, flaps with adequate subcutaneous tissue help to prevent adhesions from developing in repaired tendons. The dorsalis pedis foot flap proposed by Taylor and Corlett [21] can provide soft tissue coverage and a source of vascularized tendon grafts.

Many dorsal hand wounds involve the loss of multiple bones, however, and thus must be handled differently. A patient requiring three metacarpals to be reconstructed would be unable to walk if the foot was used as the donor site. In these cases, the authors have replaced bone with an iliac crest bone graft as well as tendons, if needed, with grafts from the extensor digitorum communis from the foot and, frequently, soft tissue from the lateral arm. Different sites have

Fig. 17. (A, B) Functional hand with a single operation. This patient refused to have treatment of the fatty dorsal flap. (Courtesy of The Christine M. Kleinert Institute for Hand and Microsurgery, Inc., Louisville, KY; used with permission.)
Fig. 18. Dorsum of the hand shows a large wound with a proximal migrating small finger and a destroyed metacarpal head. (Courtesy of The Christine M. Kleinert Institute for Hand and Microsurgery, Inc., Louisville, KY; used with permission.)

been used if a large composite flap is needed, however.

In the staged approach to the reconstruction of dorsal hand injuries, soft tissue coverage is allowed to heal before bony reconstruction (if needed) and tendon reconstructions are performed later [22]. In 1996, Sundine and Scheker [9] compared immediate versus staged approaches to the reconstruction of these types of injuries. The interval before tendon repair varied, depending on the time needed for the soft tissues to heal and the joints to become mobile. After tendon reconstruction in a single stage, patients were placed into dynamic extensor outrigger splints and began a program of active

Fig. 19. Cartilage of the head was damaged beyond repair, and gravel was still present at the end of the fifth metacarpal. (Courtesy of The Christine M. Kleinert Institute for Hand and Microsurgery, Inc., Louisville, KY; used with permission.)

Fig. 20. Once the area has been cleaned with radical de-bridement, the defect includes the metacarpal head, which is reconstructed with a palmar plate osteoplasty, extensor tendon loss on the ring and small fingers, and a large area of skin defect. (Courtesy of The Christine M. Kleinert Institute for Hand and Microsurgery, Inc., Louisville, KY; used with permission.)

Fig. 20. Once the area has been cleaned with radical de-bridement, the defect includes the metacarpal head, which is reconstructed with a palmar plate osteoplasty, extensor tendon loss on the ring and small fingers, and a large area of skin defect. (Courtesy of The Christine M. Kleinert Institute for Hand and Microsurgery, Inc., Louisville, KY; used with permission.)

flexion and protected extension within 48 hours. The group undergoing staged reconstruction (n = 7) required, on average, 630 days (range: 335-962 days) to achieve maximal range of movement (ROM) at the metacarpophalangeal (MP) joints, whereas the group undergoing immediate reconstruction (n = 7) achieved maximal ROM in an average of 214 days (range: 75-334 days). As might be expected, the staged reconstruction group underwent more operations than the immediate reconstruction group (5.9 versus 2.1). Twice as many patients in the immediate

Fig. 21. Similar to the reconstruction using other flaps, this flap has the tendon passed through the subcutaneous tissue, which allows better extension and immediate cover. (Courtesy of The Christine M. Kleinert Institute for Hand and Microsurgery, Inc., Louisville, KY; used with permission.)
Fig. 22. The donor site is well disguised. (Courtesy of The Christine M. Kleinert Institute for Hand and Microsurgery, Inc., Louisville, KY; used with permission.)

reconstruction group (6 of 7 versus 3 of 7) returned to active employment.

The palmar aspect of the hand of a 22-year-old woodworker was spared, although he sustained a severe injury to the dorsum of the hand with a wood shaper machine (Fig. 24). The third, fourth, and fifth metacarpals were shattered, requiring bone grafts and fixation with stabilization plates

Fig. 24. Palm of the hand of this young man is intact. (Courtesy of The Christine M. Kleinert Institute for Hand and Microsurgery, Inc., Louisville, KY; used with permission.)

(Fig. 25). The dorsum of the hand showed massive loss of the skin and extensor tendons (Fig. 26). Apart from the third and fourth metacarpals,

Fig. 23. (A-D) Flexion and extension of the digits can be appreciated, and the only other procedure performed was to reduce the size of the flap for cosmetic reasons. (Courtesy of The Christine M. Kleinert Institute for Hand and Microsurgery, Inc., Louisville, KY; used with permission.)
Fig. 25. Third through fifth metacarpals are badly damaged. All three metacarpals need proper fixation with bone graft. (Courtesy of The Christine M. Kleinert Institute for Hand and Microsurgery, Inc., Louisville, KY; used with permission.)

which were plated, the fifth metacarpal was so badly damaged that it could not be plated; a Kirschner wire had to be introduced through the center of the metacarpal head as a stabilization device, and bone chips were secured with a cerclage of wire to reconstruct this metacarpal (Fig. 27). A lateral arm flap was harvested, and the tendons were passed through individual channels created in the subcutaneous tissue of the flap, fixing the grafts by Pulvertaft weaving at both ends (Fig. 28).

Fig. 26. Skin defect includes the whole dorsum of the hand and shows the lack of an extensor tendon. (Courtesy of The Christine M. Kleinert Institute for Hand and Microsurgery, Inc., Louisville, KY; used with permission.)

Fig. 27. Stabilization plate with iliac bone graft was applied to the third and fourth metacarpals, whereas a cerclage of wire was used with the fifth metacarpal to maintain chips of bone attached to the Kirschner wire, which provides the strut to recreate the metacarpal. (Courtesy of The Christine M. Kleinert Institute for Hand and Microsurgery, Inc., Louisville, KY; used with permission.)

Fig. 27. Stabilization plate with iliac bone graft was applied to the third and fourth metacarpals, whereas a cerclage of wire was used with the fifth metacarpal to maintain chips of bone attached to the Kirschner wire, which provides the strut to recreate the metacarpal. (Courtesy of The Christine M. Kleinert Institute for Hand and Microsurgery, Inc., Louisville, KY; used with permission.)

Forty-eight hours after reconstruction, the patient was placed in an extensor outrigger (Fig. 29). The patient obtained good flexion and extension of the right hand (Fig. 30), showing good bone healing 3 years later when the plate was removed (Fig. 31).

Scheker and colleagues [23] showed that delay in repairing tendon defects on the dorsum of the hand resulted in adhesions, even if tendon grafts, if necessary, were passed below a previously placed flap. Secondary tendon repair was associated with extension and flexion deficits of repaired and grafted tendons. Improving function required

Fig. 28. Once the bone graft, tendon graft, and flap have been applied, the hand has only the flap showing. (Courtesy of The Christine M. Kleinert Institute for Hand and Microsurgery, Inc., Louisville, KY; used with permission.)
Fig. 29. In the first 48 hours, the patient is placed in an extensor outrigger that allows mobility of the tendon, preventing adhesions to the underlying structures. (Courtesy of The Christine M. Kleinert Institute for Hand and Microsurgery, Inc., Louisville, KY; used with permission.)

multiple reconstructive procedures. Patients with single-stage procedures had fewer operations and recovered in a shorter time; thus, there is an economic benefit not only for the health care system but for the patient.

The controversy regarding primary reconstruction dates from the work of Scheker and colleagues [23], who showed excellent results when all the reconstruction was done in a single-stage reconstruction of massive dorsal hand injuries in which bone graft, extensor tendon, and soft tissue

Fig. 31. Three years after reconstruction, the patient requested that the plates be removed so as not to have metal in his body. (Courtesy of The Christine M. Kleinert Institute for Hand and Microsurgery, Inc., Louisville, KY; used with permission.)

were required. This was confirmed by Sundine [9], who compared immediate versus staged reconstruction. An opposing view was that of Cautilli and Schneider [24], who found that multiple operations were required to obtain good results in the reconstruction of massive tendon loss on the dorsum of the hand. Similar controversy surrounds the necessity of immediate coverage versus

Fig. 30. Flexion (A) and extension (B) of the right hand. (Courtesy of The Christine M. Kleinert Institute for Hand and Microsurgery, Inc., Louisville, KY; used with permission.)

delayed coverage. The advantage of using a free flap is that the flap carries a new blood supply and, unlike dressings, protects the wound by contributing to the distribution of antibiotics and elements of the immune system to this area.

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