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An alternative approach in the treatment of thumb web contracture skin defects: lateral tarsal artery
flap
HUANG Dong1*, WANG Hong-gang2, ZhAO Cheng-yi 3 ,WU Wei-zhi 1,
Author affiliation:
1
Department of Orthopedics, NO.2 People's Hospital of Guangdong Province, Guangzhou, 510317, China;
2
Department of Orthopaedics & Microsurgery, The First Affiliated Hospital of Sun Yat -Sen
University, Guangzhou 510080, China; 3Department of orthopaedics, Zhongshan City People's Hospital,
Zhongshan, 528403, China
* Corresponding author: HUANG Dong（黄东）
Department of Orthopedics, NO.2 People's Hospital of Guangdong Province,
Guangzhou, 510317, China（广东省第二人民医院骨科）
Tel：+86-20-8916-8156; Fax: +86-20-8916-8013
E-mail：[email protected]
Grant sponsor: The Natural Science Foundation of Guangdong Province;
8151031701000001
1
Grant
number:
ABSTRACT
Background Thumb web contracture is a common complication after hand injury, and can markedly affect
whole hand function. Therefore, surgery involving thumb web reconstruction is often necessary to restore
normal function of the involved hand. In this study, we present the application of the lateral tarsal artery
(LTA) flap in first web reconstruction.
Methods From November 1, 2005 to October 31, 2007, seven patients with severe post trauma or burn
contractures around the first web space were treated with a LTA flap.
Results All flaps survived, with an average size of 6.7×4.8 cm. There were no complications or recurrent
contractures during follow-up. All patients were satisfied with the esthetic appearance and functional
outcome of the reconstruction.
Conclusion The LTA flap could be an excellent option for covering various defects in the thumb web
space, serving as an excellent alternative for the thumb web space reconstruction.
Key words: thumb web contracture; lateral tarsal artery flap; reconstruction
INTRODUCTION
Thumb web contracture is a common complication after hand injury, which has a tremendously negative
effect on whole hand function. Surgery including both wide release of the contracture and recovery of the
skin and soft tissue defect is required at the thumb web space. Various reconstructive options for the thumb
web defect include distant flaps,1 local island flaps, 2 and free-tissue transfer.3 The role of free-tissue transfer
in reconstructing the severe skin defects in the thumb-index web space is well-established.4-5 The technique
of foot-to-hand transfer has also been well reported in the literature. 6 However, as a free flap at the dorsal
pedis, the lateral tarsal artery (LTA) flap has been rarely reported in the related literature. The LTA flap has
obvious advantages in coverage of hand skin defect including a suitable vessel diameter, similar color and
texture to hand, and acceptable donor site morbidity. In this article, we present the application of the LTA
flap in the first web reconstruction.
PATIENTS AND METHODS
Clinical data
From November 1, 2005 to October 31, 2007, seven patients (five men and two women, mean age 28 years,
range 18–49 years) with severe post trauma or burn contractures around the first web space were treated with
the LTA flaps in our hospital. Informed consent was obtained from each patient after they received a full
surgical explanation.
2
Classification of thumb web contracture
Thumb web contracture is classified as mild, moderate, or severe, depending upon the magnitude of
contracture and/or scarring of the thumb web contents (skin, muscle, fascia, and joint capsule), the seventy of
impairment of thumb mobility, and the method necessary to resurface the defect produced by the contracture
release. 7 In our research, we classified the thumb web contracture according to previous criteria 8: the thumb
web width measured is the distance from the ulnaris point of thumb interphalangeal joint’ transverse striation
to the radialis point of index finger metacarpophalangeal joint’ transverse striation when the thumb is in the
maximal abduction position. The involved thumb web width is then compared with the normal side. A mild
contracture’s thumb web width is more than half of the normal side; a moderate contracture’s width is
between one-half and one-third; and a severe contracture’s width is less then one-third of the normal side. By
this method of classification, all seven cases in our series classified as moderate and severe contractures.
Surgical anatomy
The LTA flap is an artery flap based on septocutaneous or musculocutaneous perforators supplied by the
LTA. It arises from the dorsal pedal artery, as that vessel crosses the navicular bone; it passes in an arched
direction lateralward, lying upon the tarsal bones, and covered by the Extensor digitorum brevis; it supplies
this muscle and the articulations of the tarsus, and anastomoses with branches of the arcuate, anterior lateral
malleolar and lateral plantar arteries, and with the perforating branch of the peroneal artery. Along its course
in the intermuscular septum, the LTA gives multiple cutaneous and muscular branches. The septocutaneous
branches arise vertically and feed the rich arborizing and interconnected plexus under the skin of lateral
dorsal aspect of foot (Figure 1).
Operative technique
All cases were operated on as described subsequently. The operation was performed under tourniquet control
and loop magnification with the aid of general anesthesia. The contracted first web space was released with a
linear midline incision, resulting in a skin defect on both the palmar and dorsal side of the first web space.
Not only was a relaxing incision made on the contracture tissue but also a radical excision of all contracting
bands and scar tissue, which was vital for complete release. Release of skin, palmar fascia, deep fascia,
muscle origins or tendon insertions, ligaments, and scar needed to be as radical as necessary to provide
unrestricted abduction and opposition of the thumb metacarpal base. A tight, restricting thumb
carpometacarpal joint capsule was incised or excised. Dissection and release needed to come down palmarly
and dorsally ‘hinge-to-hinge’ at the thumb carpometacarpal joint.
Flap harvest and transplant
The patency of the dorsal pedis artery and LTA were all confirmed preoperatively with Doppler
ultrasonography. The LTA axis of the LTA flap arose from the dorsal pedis artery at the level of
talonavicular articulation. A line drawn from the middle point of talonavicular articulation level to basilar
part of the fifth metatarsal bone was regarded as the surface project of LTA. The soft tissue defect after the
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release of contracture was templated and an appropriate flap was mapped out on the skin territory of the LTA
flap. The design of the flap was in the shape of a spindle (Figure 2A).
A straight incision was made at the middle point of talonavicular articulation level, and the dorsal pedis
artery was located between the extensor hallucis longus tendon and extensor digitorum longus tendon. The
LTA was exposed along the fibula side of dorsal pedal artery (Figures 2B and 2C). The LTA vena comitans,
and lateral dorsal cutaneous nerve of foot were carefully protected during the dissection until they perforated
into the cutaneous. The flap was raised at the subfascial level, and sutured around to prevent the fascia and
skin from separating in the course of dissection. After the flap was totally elevated (Figure 2D), the donor
site was covered by a full skin graft from the abdomen (Figures 2E and 2F). The free flap was transplanted to
the defect area by LTA anastomosing with dorsal branch of radial artery, the LTA’s venae comitantes
anastomosing with radial artery venae comitantes or cutaneous venous under the palmar skin, and the lateral
dorsal cutaneous nerve of foot anastomosing with dorsal branch of radial nerve. An arciform K-wire is
inserted into the first and second metacarpals to keep the web space in complete abduction. Some drainage
strips was used to prevent hematoma formation, and the K-wire was removed after 3 weeks. A short-arm
plaster splint was applied for 3 weeks and a rehabilitation program would begin at its removal.
RESULTS
All flaps survived without complication. The largest skin flap was 7.5×5.3cm, with an average size of
6.7×4.8 cm (range 6.0–7.5×4.3–5.3cm). All wounds healed in 3 weeks. All patients were followed up for at
least 12 months, and the follow-up ranged from 12–32 months (mean, 18 months). There was no recurrent
contracture or hypertrophic scars noted in hand during the follow-up. All patients were satisfied with the
esthetic appearance and functional outcome of the reconstruction. We were able to achieve an average
abduction distance of 8.0 cm (range 7.2–9.0 cm), compared to the preoperative assessment of 3.9 cm (range
3.4–4.4 cm); and space angle of the thumb web space of 81.0° (range 75–88°), compared to the preoperative
assessment of 15.1° (range 12–20°).
Case report
An 18-years-old male presented with a severe scar contracture at the thumb web space of left palm after
having suffered a crush injury. After extensive release of the thumb web contracture, a LTA free flap
measuring 7.5×4.8cm was transferred from the right foot to the defect. The pedicle was anastomosed
end-to-end to the dorsal branch of radial artery and the cutaneous vein at the anatomic snuffbox, and the
lateral dorsal cutaneous nerve of foot was anastomosed to the dorsal branch of radial nerve. The flap survived
completely and contracture improved enough to enable the patient to open the thumb completely (Figure 3).
DISCUSSION
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The function of the thumb is critical to overall hand function. Uniquely endowed with anatomic features that
allow circumduction and opposition, the thumb enables activities of pinch, grasp, and fine manipulation that
are essential in daily life. But, contracture of the thumb web space induced by trauma or burn negates the
ability of the thumb to diverge from the remainder of the hand and, consequently, to decrease the whole hand
function greatly. Thumb web is a complex, multilayered anatomic region spanning the first and second
metacarpals. It has a triangular shape, with its vertex located at the base of the first and second metacarpals;
the skin web that joins the metacarpophalangeal joints of the index finger and thumb corresponds to its base.
Thumb web contracture often result from trauma and thermal burn. Opposition, the primary function of the
thumb, would be directly impaired in those conditions. Therefore, the surgery involvement of thumb web
reconstruction often is necessary for restore the normal function of involved hand.
In this type of hand-rescue operations, the selection of the appropriate patients is crucial since releasing the
unmovable joint means nothing. There should not be any major problem with range of motions of these
affected joints by scar contracture. After release of the contracture for the severe case of thumb web
contracture, deep soft tissue is exposed, then the skin and soft tissue defection needs appropriately covered
by all kinds of flaps. There are some types of flaps have been used in coverage of thumb web space defects,
including abdominal flap, cross-arm flaps, pedicled antebrachial flap, even free flap graft.
Two-stage procedures such as abdominal flaps and cross-arm flaps require 2–3 weeks of immobilization and
are often bulky and require subsequent revision. 9,10 Local flap such as pedicled antebrachial flap can
reconstruct the thumb web in one-stage, avoid hand dependency, and permit early mobilization. However, its
main disadvantage relates to the sacrifice of a major vessel.11 According to the progress of microsurgery, the
applications of free flaps have become increasingly popular. Among those free flaps, the anterolateral thigh
flap has become the standard flap for soft-tissue defects, but it is bulky applied in the hand, and the toe web
flap has the similar texture to hand but its application is limited by its size. 12,13 Dorsalis pedis or medial
plantar free flaps would sacrifice a major vessel.14,15
In our experience, we believe that the LTA flap is suited for resurfacing the thumb web space. Anatomical
research in the literature demonstrates that the external diameter of the lateral tarsal artery is 1.42  0.34 mm,
length is 6.2  1.1 cm, and patency of the LTA is 100%.16,17 The advantages of LTA are obvious and include
suitable vessel diameter, similar color and texture to hand, and acceptable donor site morbidity.18-21 In our
cases, the results of treatment confirm the anatomic basis of the LTA flap for application as a free flap, which
can be devised according to the different repair regions to restore the defected soft tissues of the hand.
However, basic microsurgery technique is necessary in using this method. Additionally, the skin graft on the
foot is prone to hypertrophic scarring caused by friction of the skin graft against footwear when patients are
walking. Patients must be informed of this problem before surgery.
5
Notwithstanding, the well-recognized donor site morbidity, we found enhanced recovery of function and
cosmesis by application of the LTA flap. Our series demonstrates that the LTA flap is an excellent alternative
approach for reconstructing thumb web contraction.
On the whole, the thin LTA flap represents an excellent option for covering various defects in the thumb web
space. The LTA flap provides a thin, pliable, vascularized tissue for replacing the skin in particular areas,
such as the thumb web space.
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REFERENCES
1. Lu LJ, Gong X, Lu XM, Wang KL. The reverse posterior interosseous flap and its composite flap:
experience with 201 flaps. J Plast Reconstr Aesthet Surg 2007; 60:876-882.
2. Prakash V, Mishra A. Management of adduction contracture of the thumb with a prefabricated radial
fascial flap. Plast Reconstr Surg 2004; 114:1681-1682.
3. Adani R, Tarallo L, Marcoccio I, Cipriani R, Gelati C, Innocenti M. Hand reconstruction using the thin
anterolateral thigh flap. Plast Reconstr Surg 2005; 116:467-473.
4. Fan CY, Jiang J, Zeng BF, Jiang PZ, Cai PH, Chung KC. Reconstruction of thumb loss complicated by
skin defects in the thumb-index web space by combined transplantation of free tissues. J Hand Surg Am
2006; 31:236-241.
5. Eo S, Kim Y, Kim JY, Oh S. The versatility of the dorsalis pedis compound free flap in hand
reconstruction. Ann Plast Surg 2008; 61:157-163.
6. Zhang YX, Wang D, Zhang Y, Ong YS, Follmar KE, Tahernia AH, et al. Triple chimeric flap based on
anterior tibial vessels for reconstruction of severe traumatic injuries of the hand with thumb loss. Plast
Reconstr Surg 2009; 123:268-275.
7. Sandzen S C, Jr. Thumb web reconstruction. Clin Orthop Relat Res 1985; 195:66-82.
8. Gu YD W M, Zheng YL The etiology, prevention, and treatment of thumb web's contraction. Chin J
Orthope 1986; 6:1-3.
9. Miura T. Use of paired abdominal flaps for release of adduction contractures of the thumb. Plast
Reconstr Surg 1979; 63:242-244.
10. Bonola A, Fiocchi R. Cross-arm double flap in the repair of severe adduction contracture of the thumb.
Hand 1975; 7:287-290.
11. Timmons MJ, Missotten FE, Poole MD, Davies DM. Complications of radial forearm flap donor sites.
Br J Plast Surg 1986; 39:176-178.
12. Kuo YR, Seng-Feng J, Kuo FM, Liu YT, Lai PW. Versatility of the free anterolateral thigh flap for
reconstruction of soft-tissue defects: review of 140 cases. Ann Plast Surg 2002; 48:161-166.
13. Dabernig J, Shelley OP, Schaff J. The innervated free toe web flap for clitoris reconstruction. J Plast
Reconstr Aesthet Surg 2007; 60:1352-1355.
14. Ritz M, Mahendru S, Somia N, Pacifico MD. The dorsalis pedis fascial flap. J Reconstr Microsurg 2009;
25:313-317.
15. Duman H, Er E, Işík S, Türegün M, Deveci M, Nişancí M, et al. Versatility of the medial plantar flap:
our clinical experience. Plast Reconstr Surg 2002; 109:1007-1012.
16. Sham E, Choi WT, Flood SJ. Lateral supramalleolar flap in reconstruction of pressure ulcers in patients
with spinal cord injury. ANZ J Surg 2008;78:167-171.
17. Touam C, Rostoucher P, Bhatia A, Oberlin C. Comparative study of two series of distally based
fasciocutaneous flaps for coverage of the lower one-fourth of the leg, the ankle, and the foot. Plast
Reconstr Surg 2001; 107:383-392.
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18
Hashimoto I, Yoshinaga R, Toda M, Nakanishi H. Intractable malleolar bursitis treated with lateral
calcaneal artery adipofascial flap. Br J Plast Surg 2003; 56:701-703.
19 Borrelli J Jr, Lashgari C. Vascularity of the lateral calcaneal flap: a cadaveric injection study. J Orthop
Trauma 1999; 13:73-77.
20 Andermahr J, Helling HJ, Landwehr P, Fischbach R, Koebke J, Rehm KE. The lateral calcaneal artery.
Surg Radiol Anat 1998; 20:419-423.
21 Lee JH, Dauber W. Anatomic study of the dorsalis pedis-first dorsal metatarsal artery. Ann Plast Surg
1997; 38:50-55.
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Table 1. Evaluation of the recovery after thumb web reconstruction.
Age
(year) /
Gender
Size of defect
(cm)
Normal side
Preop.
Postop.
Preop.
Postop.
1
25/M
6.0×4.5
10.5
3.9
7.8
12°
75°
2
18/M
7.5×5.3
11.0
4.4
9.0
20°
88°
3
32/F
6.2×4.7
9.5
3.8
8.0
15°
82°
4
45/M
7.2×5.0
12.2
4.0
8.2
14°
80°
5
21/M
6.0×4.4
10.4
3.4
7.2
13°
75°
6
38/M
6.2×4.3
12.0
3.9
7.5
14°
82°
7
18/F
7.0×5.0
9.0
3.8
8.2
18°
85°
Case No.
Abduction distance (cm)
Preop. indicates preoperative; Postop. indicates postoperative.
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Space angle
Figures
Figure 1. The anatomy of LTA and LTA flap.
DPA:dorsal padel artery; LTA: lateral tarsal artery; LTA flap: the flap based on lateral tarsal artery
(From Wang Zeng-tao: Clinical Anatomic Atlas of Microsurgery, 2009 )
10
Figure 2. The LTA flap design and harvest.
A, Design of LTA flap; B, Dissection of LTA flap; C, LTA (black arrow) and its venae comitantes (yellow arrow); D, LTA flap and
its vessel pedicle; E, Donor side covered by skin graft; F, the postoperative outcome of donor site.
LTA flap：the flap based on lateral tarsal artery
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Figure 3. The left thumb web contracture treated with the free LTA flap.
A, Preoperative condition of the thumb web contracture; B and C, Postoperative condition of the treatment with the free LTA flap;
D-F, Final outcome of the hand function after the reconstructive operation.
LTA flap：the flap based on lateral tarsal artery
12