Assessment of the Gliding of Extensor Tendons in Post-Traumatic Hand Defects Reconstructed Using Muscle Flaps Versus Fascio-Cutaneous Flaps

INTRODUCTION
Fascial flaps are considered the best option for
coverage of dorsal hand defects as it creates a
gliding surface to facilitate tendon and joint mobility
[1]. Multiple fascial flaps were used as lateral
arm flap [2], radial forearm flap [3], temporo-parietal
fascia [4], dorsal ulnar forearm[5], posterior interosseous
flap [6], dorsal thoracic [7]. The use of
muscle free flaps is well known especially for large
defects as latissimus and rectus free flaps [8-11].
The gliding surface of the dorsum of the hand
is crucial for tendon movement, but when there
285
are large defects, options may be limited due to
paucity of the donor tissues to supply flaps with
huge dimensions especially in those defects involving
the hand dorsum with wrist and distal forearm
skin loss. So the use of large, robust muscle flaps
to cover those large skin defects were introduced
as free latissimus and rectus muscles.
Many studies had recorded the use of muscle,
fascio-cutaneous, fascial and venous flaps and they
found that fascia and muscle flaps scored equally
in terms of overall aesthetics, color, and contour
match, while fascio-cutaneous flaps had significantly
worse aesthetic, contour, and color match results
compared with all other flap types [12]. To our
knowledge there is no any other study that compared
in between these flaps in terms of tendon gliding.
The tendons of the hand pose a particular challenge
for the hand therapist, as full hand function requires
the tendon to glide long distances [13].
PATIENTS AND METHODS
This prospective comparative study was done
through September 2014 till January 2017. Written
informed consent was obtained from each patient.
All patients included were suffering from posttraumatic
skin and soft tissues defect over the
dorsum of the hand; with or without extension to
the distal one third of the forearm; exposing the
underlying tendons of all ages, no specified gender.
The exclusion criteria were any associated
tendon injury or associated fractures, history of
any related hand injuries or surgeries, history of
rheumatoid arthritis, diabetes mellitus, or osteoporosis,
the presence of central or peripheral
nerve injuries.
The experimental methods were carried out in
accordance with approved guidelines and regulations
of our institution.
Twenty patients shared in this study and they
were divided into two groups the first group of
patients' (n=10) hand defects were early reconstructed
by muscle flaps and split thickness skin
grafts, the second group of patients' (n=10) defects
were early reconstructed using fascio-cutaneous
flaps.
Early postoperative rehabilitation was the protocol
following immobilization in the first 3-5 days
after flap inset [14]. Passive range of motion guided
by pain was applied, later on; at two weeks later
scar stretching was done [16]. Once healed, active
range of motion exercises coupled with ultrasound
[17] and later on return to work [18].
The metacarpo-phalangeal joint active and
passive range of motion angles were measured
using goniometer after flap inset by four month in
both groups. Statistical Analysis of the results
using SPSS (statistical program for social science)
as follows; Description of quantitative variables
as mean and standard deviation (SD). Pearson's
Correlation coefficient (Pearson's r) was used to
rank different variables versus each other (where
1 or -1 are highly related with linear relationship,
whilst 0 signifies no linear correlation). The pvalue
was calculated and correlated to the variants
and p-value was considered insignificant if >0.05,
significant if <0.05 and highly significant if <0.01.
RESULTS
The mean age for patients was 38.3±13.3 years.
Eighteen male and two female patients who were
suffering from dorsal hand defects exposing the
extensor tendons. In group I; defects were reconstructed
using free muscle flaps (eight rectus abdominis
and two latissimus dorsi) followed by skin
grafting. In group II; defects were reconstructed
by fascio-cutaneous flaps (eight reversed flow
posterior interosseous artery and two reversed
radial forearm flaps). All flaps healed well however
one posterior interosseous artery flap suffered
congestion and partial loss, one reversed radial
forearm flap suffered disruption that was treated
by secondary sutures and one skin graft over a free
rectus flap that suffered partial loss.
Active and passive ranges of motion (ROM)
for the metacarpo- phalangeal joint (MPJ) movement
for both groups were measured. Concerning
group I, the mean for passive ROM was 111.4±8.14
degrees, the mean for active ROM was 75.4±34.11
degrees (Table 1). Concerning group II, the mean
for passive ROM was 111.16±7.91 degrees, the
mean for active ROM was 89.3±31.7 degrees (Table
2). Passive and active ROM at the MPJ were meas-
286 Vol. 42, No. 2 / Assessment of the Gliding of Extensor Tendons in Post-Traumatic Hand
ured and the difference was calculated in the two
groups and shown in Tables (1,2).
Tenolysis was needed in four cases; two belonged
to each group I, II. On comparing the values
for active ROM for all patients in the two groups
I and II, we found very weak inverse linear relationship
by Pearson's correlation coefficient (Pearson's
r) = –0.135 and also we found that probability
of Null hypothesis (p-value) = 0.687; that means
that, there is no significant difference in active
ROM between the two groups at four months
postoperatively.
DISCUSSION
Fascial and fascio-cutaneous flaps provide thin
and mobile coverage with reliable vascular supply,
potential for sensibility, and most importantly a
gliding surface to facilitate tendon and joint mobility
[19]. In large hand and forearm defects, fascial
and fascio-cutaneous flaps may show some limitations
especially in females, due to large donor
sites. In case of large defects, muscle flap offers
large surface area for coverage, with less cosmetic
morbidity, as rectus and latissimus free muscle
flaps.
In reconstruction of dorsal hand defects, it is
very helpful to use muscle free flaps, but concerns
may arise about the gliding surface of the tendons
underneath the muscle flap. This study was intended
to compare the gliding surface offered to the extensor
tendons underneath fascio-cutaneous and
muscle flaps on the dorsum of the hand. The study
compared twenty patients with soft tissue defects
over the dorsum of the hand with or without extension
to the wrist and distal forearm.
In group I, we used free muscle flaps (eight
rectus, two latissimus). All flaps were anastomosed
to the radial artery and the cephalic vein except
one flap, venous anastomoses was done to the
basilic vein. The donor sites of the flaps were
closed and no complications concerning the donor
site occurred. All flaps healed well and the split
thickness skin grafts were applied within range of
6-11 days. One graft suffered partial loss, while
all other skin grafts healed uneventfully (Figs.
1,2). In group II fascio-cutaneous flaps used were
the reversed flow posterior interosseous artery flap
(8 cases) and the reversed radial forearm flap (2
cases), (Fig. 3). All flaps passed uneventful, except
for partial loss in one posterior interosseous flap;
that healed by secondary intension and one reversed
radial forearm flap suffered from disruption and
underwent secondary suturing.
Egypt, J. Plast. Reconstr. Surg., July 2018 287
Table (1): Results for Group I that used free muscle for coverage.
1
2
3
4
5
6
7
8
9
10
Passive ROM in
MPJ at 4 month
Active ROM in
Flap MPJ at 4 month
survival
Good
Good
Partial loss of the
skin graft and left to
heel secondarily
Good
Good healing
Good healing
Good healing
Good healing
Good healing
Good healing
Case
number Age
22
43
66
28
26
47
29
24
34
41
Gender
Male
Male
Male
Male
Male
Male
Male
Male
Male
Male
Location
Dorsum of the
hand and wrist joint
Dorsum of thehand,
wrist and distal forearm
Dorsum of the
hand and wrist
Dorsum, radial and volar
surfaces of the hand
Dorsum of the and
the distal forearm
Dorsum of the hand
Dorsum of the hand
Dorsum of the hand
and the first web space
Dorsum of the hand
and the wrist joint
Dorum of the hand,
wrist and forearm
Coverage
used
Free rectus
and STSG
Free rectus
and STSG
Free rectus
and STSG
Free latissimus
and STSG
Coverage by free
rectus and STSG
Coverage by free
rectus and STSG
Coverage by free
rectus and STSG
Coverage by free
rectus and STSG
Coverage by free
rectus and STSG
Free latissimus
and STSG
80
79
78
85
89
87
79
88
90
72
Flexion Extension
30
24
32
28
27
35
29
32
27
23
Whole range of
passive motion
for group I
110
103
110
113
116
122
108
120
117
95
70
60
15
70
66
78
10
60
72
67
Flexion Extension
20
15
0
25
23
30
0
30
20
23
Whole range of
active motion
for group I
90
75
15
95
89
108
10
90
92
90
Need for
tenolysis
Needed
tenolysis
Needed
tenolysis
288 Vol. 42, No. 2 / Assessment of the Gliding of Extensor Tendons in Post-Traumatic Hand
Table (2): Results of Group II that used fascio- cutaneous flaps.
1
23
4
5
6
7
8
9
10
Passive ROM in
MPJ at 4 month
Active ROM in
Flap MPJ at 4 month
survival
Good
Complete healing
Complete healing
Complete healing
Partial disruption
of the flap+
secondarysutures
Good healing
Good healing
Good healing
Good healing
Congestion+partial
loss ® complete heali
Case Age
32
50
47
43
35
23
60
32
25
60
Gender
Female
Male
Male
Male
Female
Male
Male
Male
Male
Male
Location
Dorsum of hand
Dorsum of hand
Dorsum and ulnar
side of hand
Dorsum of hand
Dorsum of hand and
dorsum of the first
web space
Dorsum of hand
Dorsum of hand
Dorsum of hand
Dorsum of hand and
ulnar side of the hand
Dorsum of hand
Coverage
used
Radial
forearm flap
PI artery flap
PI artery flap
PI artery flap
Radial
forearm flap
Coverage by
PI flap
Coverage by
PI artery flap
Coverage by
PI artery flap
Coverage by
PI artery flap
Coverage by
PI artery flap
85
90
80
82
79
87
80
82
79
78
Flexion Extension
40
35
37
34
31
40
29
38
25
32
Whole range of
passive
movement
125
125
117
116
110
127
109
120
104
110
Flexion
70
80
75
50
70
80
70
80
10
69
Extension
30
30
30
13
25
38
20
30
0
23
Whole range of
active
movement
100
110
105
63
95
118
90
110
10
92
Need for
tenolysis
Needed
tenolysis
Needed
tenolysis
PI®Posterior Interosseous Artery Flap.
Egypt, J. Plast. Reconstr. Surg., July 2018 289
Fig. (1): 47 years old male patient; the photo to the left shows post traumatic avulsion hand
defect. Middle photo shows free rectus flap inset. The photo to the right shows the
flap after healing 42 days postoperatively.
Fig. (2): 28 years old male patient; the upper photos shows the hand defect that runs from the
dorsum of the hand, then along the radial side and the volar side of the hand. The
lower photos show after free latissimus flap inset.
Fig. (3): 23 years old male patient; the left photo shows dorsal
hand defect. The right photo shows reversed flow
posterior interosseous artery flap inset.
Postoperative rehabilitation was a crucial step
as it helped the hand regain its functions early and
prevent adhesions [16,17]. Early postoperative
physiotherapy was done following immobilization
for the first 3-5days after flap inset that was required
to enable flap healing [14]. Following immobilization,
passive range of motion for all hand
joints was applied [15]. Two weeks later on, scar
stretching with active range of motion guided by
pain was done [16]. Once healed, massage began
gradually to soften and mobilize tissues. Rehabilitation
coupled with ultrasound massaging improved
patients joints and prevented forthcoming
deformities [17]. Later on return to work, also
graded rubber exercise bands and springs increased
muscle strength [18].
In our study we have chosen the MPJ range of
motion based on the fact that the amplitude of
tendon excursion along the dorsum of the hand is
the highest compared to the fingers that shows
very low tendon excursion due to its intricate and
delicate anatomy. Tendon excursion is the distance
travelled by the tendon when the muscle is in
complete action and complete relaxation. The
amplitude of tendon excursion for the finger extensors
is 5cm, most of it, occurs in the forearm,
wrist and dorsum of the hand [20]; therefore the
measurement of the flexion and extension of the
MPJ reflects the tendon gliding over the dorsum
of the hand. The normal range of motion of the
MPJ is ninety degrees in flexion and forty five
degrees in extension in average normal individuals.
We measured the active ROM at the MPJ after
four months of flap inset to measure the tendon
gliding underneath the flaps, also we examined
the passive ROM and calculated the difference
(extensor lag) to define the need for tenolysis. In
four cases; two belonging to each group, tenolysis
was needed. The results of our study showed that
there was no statistical significance (Pearson
r=–0.13, p-value=0.68) between the active range
of motion in the MPJ in both groups, therefore the
use of muscle free flaps as a durable coverage for
the dorsum of the hand didn't decline the extensor
tendons gliding.
Conclusion:
Both the fasciocutaneous and muscle flaps are
reliable as durable coverage for dorsal hand defects
with no significant difference in underneath extensor
tendon gliding.