Chapter 43 Complex Reconstructions in Hand Surgery
Many complex reconstructions are undertaken when movement after trauma or surgery does not produce ideal function. The goal is usually to restore useful movement of the wrist, thumb, and fingers. Patients with sedation, a motor block, or a tourniquet are not able to move reconstructed parts during surgery in comfort. WALANT permits them to do just that. Furthermore, the surgeon can adjust the reconstruction to make it work if the preoperative plan is successful when patients move reconstructed fingers or thumbs during the surgery. The more complex the reconstruction, the more helpful WALANT can be. We present a video series of cases to illustrate this point.
Clip 43-1 shows a repair of a 5½-week-old flexor pollicis longus (FPL) laceration. We did not know which operation would be possible or best—primary repair, primary palmaris longus tendon graft, or tendon transfer of the long finger flexor digitorum superficialis (FDS). We injected local anesthetic for all three possibilities and made our decision based on active movement by the patient during the surgery.
Clip 43-2 demonstrates a change in thumb tip pinch after adult pollicization. This patient had an adult pollicization of the index finger after a failed thumb replantation. Years later, he requested better thumb tip pinch and was able to participate in selecting the perfect angle during the surgery.
Clip 43-3 describes cleaning a severely contaminated hand wound in the emergency department. This illustrates how we wash very contaminated wounds with tap water after adequate local anesthetic is administered in the emergency department.
Clip 43-4 shows a complex secondary reconstruction with extensor tendon grafting where intraoperative active movement demonstrated that the preoperative plan of simple tendon graft insertion failed because it did not extend the proximal phalanx adequately. We added graft suturing to the proximal extensor hood of the proximal phalanx to the preoperative plan because of intraoperative active extension observation and were ultimately successful.
Clip 43-5 is of a complex extensor tendon transfer case. The patient had had polio 50 years earlier, which resulted in muscle dysfunction of the entire upper limb and shoulder fusion. She subsequently fractured her humerus and acquired a postplating radial nerve palsy. We planned a flexor carpi radialis (FCR) and flexor carpi ulnaris (FCU) transfer procedure. We saw the true active excursion of the polio affected muscles at surgery that altered the preoperative plan with ultimate success.
Clip 43-6 shows a finger revascularization with wrist vein grafts by Dr. Jason Wong. The patient had sustained a severe crush injury to all four digits of the left hand, with delayed presentation that rendered the index and middle fingers nonsalvageable. The ring and little fingers were salvaged using the WALANT technique.
In Clip 43-7 a homodigital island flap was performed by Dr. Jason Wong. This was a case of fingertip reconstruction with a local pedicled island flap with WALANT anesthesia. Active movement during surgery shows correct tension of the inserted pedicle.
In Clip 43-8 thumb extension was restored after a subtotal amputation. This subtotal amputation of a thumb ended up without extensor pollicis longus (EPL) function. We injected enough local anesthetic to allow extensor indicis proprius (EIP) tendon transfer if the EPL muscle had been too short to permit simple tendon repair.
Clip 43-9 shows a WALANT FPL repair under the motor branch in the carpal tunnel. The patient ruptured the repair. We also show the secondary repair with WALANT 8 days after the initial repair. Postoperative management of both operations is explained.
Clip 43-10 shows a swan neck flexor digitorum superficialis (FDS) transfer. We sutured the proximal FDS of the small finger to the proximal phalanx with a bone anchor to correct a swan neck deformity. Active movement during the surgery shows the correct selection of tension.
In Clip 43-11 a woman in her late sixties presented with rupture of the fourth and fifth extensors of her left hand. We harvested a palmaris longus tendon graft and hooked it up to proximal tendon stump motors that still had good active excursion. We strengthened the repair with a transfer to the long finger extensor and performed a tenodesis of the extensor digiti minimi, all decisions based on active movement at the time of surgery.
We have found that secondary reconstructions of the hand and fingers in awake pain-free patients have the great benefit of adding voluntary active movement during the surgery. We have often been pleasantly surprised, as we have been in the cases presented here, that outcomes have been improved because of intraoperative adjustments on reconstructed parts based on what we see with patients moving. It has become our method of choice where the goal of the operation is to improve active function.