66 Stiff Fingers and Elbow after Replantation
66.1 Patient History Leading to the Specific Problem
A 21-year-old, right-handed woman was a victim of motorcycle accident 1 year ago. She underwent a free groin flap for her left volar wrist soft-tissue defect and a transposition flap and skin graft for dorsal hand skin defect. In addition, she suffered from left elbow intra-articular fracture. She received a split-thickness skin graft (STSG) for her left elbow skin defect within the first month after trauma in the first hospital visit. She sustained left wrist and carpal bones posttraumatic fusion with functional impaired left hand, so she went to another hospital for a left wrist Suave–Kapandji procedure.
She presented to us with left hand extrinsic and intrinsic tightness. The left thumb ray was stiff and unopposable (▶Fig. 66.1).
66.2 Anatomical Description of the Patient’s Current Status
This patient demonstrated left hand stiffness with limited pronation and supination because of tissue fibrosis after trauma and repeated surgeries. She had little active flexion on the thumb, index, and middle fingers, and inadequate ring and little finger proximal interphalangeal joint (PIPJ) flexion. The examination also revealed both extrinsic and intrinsic tightness (▶Fig. 66.2). There was no visible or palpable thenar muscle contraction. Thus, she could not oppose or circumduct the thumb ray. She had a contractured first web space with the first and second metacarpal angle of less than 15 degrees. She was supposed to have left hand flexor and extensor tendon extensive adhesion requiring tenolysis.
Fig. 66.1 (a) Left hand extension. (b) Left hand flexion failing in opposition. (c) Dorsal hand skin grafted and fibrotic. (d) Posttraumatic fused basal joint and carpal bones, after the Suave–Kapandji procedure.
Fig. 66.2 (a) Fingers exhibiting intrinsic tightness at metacarpophalangeal joint (MCPJ) extension. (b) Extrinsic tightness at MCPJ flexion.
Fig. 66.3 Both left radial and ulnar arteries occluded at the distal forearm.
The left forearm CT angiography showed both radial and ulnar arteries occluded at the distal forearm level with collateral circulation to the hand (▶Fig. 66.3).
66.3 Recommended Solution to the Problem
Opposable hand should be the essential goal for hand functional restoration. Opposable hand requires the integration of the functional thumb ray and the capability of the flexible fingers. The thumb ray should possess adequate first web space, circumduction on the basal joint, and acceptable flexion on two of the three other thumb joints (basal joint, metacarpophalangeal [MCPJ], and IPJ).
66.3.1 Recommended Solution to the Problem
• The first ray contracture has to be released. She underwent a transposition flap and STSG for dorsal hand soft-tissue defect, which deprived the feasibility of local flap for interposition after first web-space release. Either a free flap or distant groin flap will be indicated. The hand requires flexor and extensor tenolysis, followed by early rehabilitation. Thus, a thin skin flap will be preferred as a soft tissue for web-space maintenance.
• Either forearm flap or lateral arm flap can be one of the options for the web space. Considering the radial and ulnar arteries were occluded at the distal third of the left forearm, an anterolateral thigh flap carries a sizable caliber and long pedicle will be justified.
• Left thumb basal joint and MCPJ were fused. In order to provide a mobile basal joint, a resection osteotomy on the basal joint and a suspension interpositional arthroplasty are some of the options to afford a mobile and stable basal joint. The commonly used donor tendons can be extensor carpi radialis longus (ECRL) or flexor carpi radialis. Since the wrist was fused and the resection osteotomy and free lateral arm flap would be on the dorsal hand, ECRL was recommended.
• Her thenar muscles were traumatized; an opponensplasty was indicated to provide the circumduction of the thumb ray. The donor tendon would be dependent on the surgical exploration for flexor tendon during tenolysis of the flexor tendons.
66.4 Technique
The first web space on her left hand was released, including the scar contractured intrinsic fascia. An opening of 60 degrees was obtained. The ECRL and extensor carpi radialis brevis (ECRB) were explored at the distal dorsal forearm, and a resection osteotomy was performed on the fused first carpometacarpal joint. A drill hole was created at the first metacarpal base and a split ECRL was used to suspend the first metacarpal to the second metacarpal base. The excess ECRL and ECRB were used as an interposition arthroplasty. The extrinsic extensor tenolysis was done to allow full passive PIP and distal interphalangeal (DIP) flexion during MCPJ flexion. A subperiosteal dissection of the intrinsic muscle was done to have PIP and DIP full passive flexion at MCPJ extension. The thumb ray was kept at abduction and circumduction position of 60 degrees with cross K-wires to both the first and the second metacarpal bones (▶Fig. 66.4).
The left radial artery and cephalic vein were harvested as recipient vessels at the distal forearm. The left anterolateral thigh flap was elevated and trimmed thin to fill the first web defect, followed by revascularization.
Four months later, she underwent left hand and forearm flexor tenolysis and ring finger flexor digitorum superficialis tendon transfer for opponensplasty through its pivot point at the flexor carpi ulnar loop. She received another subsequent flexor lysis.
