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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 3 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 4 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. 6 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. 7 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. 8 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. 9 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 11 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