THUMB DEFECT comparison regional flaps.pptx

CFF vs FDMA vs NV island

1. THUMB DEFECTS - COMPARISION OF CFF WITH FDMA & NV ISLAND FLAP Dr. T. Jawahar, MS., Ortho, ., Hand Surgery 2 nd Year Postgraduate, Institute for Research and Rehabilitation of Hand Govt. Stanley Medical College hospital, Chennai.  

2. VARIOUS TREATMENT OPTIONS IN THUMB DEFECTS Conservative Shortening closure Local advancement flaps – V-Y flap, Oblique Triangular flap, Moberg flap Regional flap- CFF, FDMA, NV Island flap Distant flap – Groin flap Microsurgery – Replant, Trimmed or Wrap around toe transfer, 2 nd toe transfer

3. INTRODUCTION The thumb accounts for 40% of the hand's overall function In thumb amputations, the neck of the proximal phalanx (PPX) is considered the critical functional length. For defects greater than 2 cm and located distal to the neck of PPX, options such as the cross finger flap (CFF), neurovascular (NV) island flap, and first dorsal metacarpal artery (FDMA) flap are highly effective. This study aims to analyze the functional outcomes following these three procedures.

4. Ideal reconstruction of thumb defects Durable tissue Glabrous skin Restoring length Avoid adjacent joint contracture Good aesthetics Sensibility

5. MATERIALS AND METHODS Prospective study Study period- January 2023 to March 2024 Study population: 41 Group 1: cross finger flap- 22 Group 2: Heterodigital Neurovascular island flap- 9 Group 3: FDMA flap - 10 Follow up period: 4 months – 18 months

6. Inclusion criteria Acute thumb injuries exposing bone or tendon. Defects > 2cm Injuries distal to PPX NECK With or without nail complex injury Age group- 13-60 years.

7. Exclusion criteria: Age group less than 12 and more than 60. Multiple finger injuries Mangled hand Previously injured and stiff index or mid finger Patient with osteoarthritis, dupuytrens contracture.

8. COMPARISION NV ISLAND FLAP FDMA FLAP CFF HETRODIGITAL ISLANDED FLAP HETRODIGITAL ISLANDED FLAP RANDOM PATTERN FLAP DONOR – ULNAR ASPECT OF MID PPX INDEX PPX DORSUM INDEX PPX DORSUM SSG FOR DONOR DEFECT SSG FOR DONOR DEFECT SSG FOR DONOR DEFECT SCB/AB SCB/AB SCB/AB SINGLE STAGE SINGLE STAGE REQUIRES FLAP DIVISION INCLUDES NERVATION BY DEFAULT CAN BE DONE INNERVATED USING DORSAL DIGITAL NERVE CAN BE DONE INNERVATED USING DORSAL DIGITAL NERVE

9. RESULTS TOTAL MALE FEMALE CFF 22 16 6 NV Island flap 9 7 2 FDMA flap 10 7 3 TOTAL 41 30 11 DOMINANT NON DOMINANT TOTAL 23 18 CFF 14 8 NV ISLAND 5 4 FDMA flap 4 6

10. MODE OF INJURY Total 41 Industrial injury 25 Chain Sprocket injury 8 Other injury 7

11. SENSATION MEAN STATIC 2PD (mm) MEAN MOVING 2PD (mm) NV ISLAND FDMA CFF NV ISLAND FDMA CFF FLAP SIDE 6+/-2mm 6.8+/-2mm 7.1+/-2.5 mm 5.5+/- 2mm 6.8+/-2mm 7.0+/-2.5mm CONTRALATERAL SIDE 3+/- 1mm 3+/- 0.6mm

12. SUBJECTIVE ASSESSMENT (QUESTIONNAIRE) POOR % FAIR % GOOD % EXCELLENT NV island CFF FDMA NV island CFF FDMA NV island CFF FDMA NV island CFF FDMA SENSIBILITY 2 1 2 6 1 3 11 5 4 3 3 FUNCTION 1 1 1 4 8 4 5 12 5 APPEARANCE 1 2 1 3 5 3 5 3 2 10 6

13. FDMA FLAP

14. FDMA FLAP

15. FDMA FLAP

16. FDMA FLAP

17. NEUROVASCULAR ISLAND FLAP

18. NV ISLAND DONOR SITE

19. CROSS FINGER FLAP

20. CFF

21. CROSS FINGER FLAP

22. CFF FDMA NV ISLAND Duration of Procedure 45 min 120 min 120 min Return to work 7 weeks 6 weeks 7 weeks Donor Site complications 3 out of 22 cases (SSG site) 1 (hypertrophic scar 1 ( extensor lag) 1 ( unsightly scar) 1 ( SSG site) Recipient Site complications 2 (flap loss) 1 (flap dehiscence) 1 (flap loss) Results

23. FDMA FLAP ADVANTAGES DISADVANTAGES Single stage Can be made innervated Less expertise when compared to NV island flap Can help cold intolerance Needs expertise Reach is difficult to volar aspect when nail complex is intact Extensor lag may occur Risk of venous congestion and necrosis Scar

24. NV ISLAND FLAP ADVANTAGES DISADVANTAGES Single stage Innervated- better sensory outcome Better appearance Can help cold intolerance Needs expertise Reach is difficult to dorsal aspect when nail complex is intact Risk of venous congestion and necrosis Scar in the palm Needs cortical reorientation

25. CROSS FINGER FLAP ADVANTAGES DISADVANTAGES Easier to perform Less duration Can be performed by beginners Less donor site morbidity Protective sensation recovered Can be made innervated Adequate reach in most of the cases Two staged procedure Non sensate flap

26. CONCLUSION Based on the patients requirement, age, co-morbidities, hand dominance, available resources, surgeons expertise and injury pattern any flaps can be considered. We found CFF is more helpful than two flaps as it is easier, faster and was able to provide protective sensation and good cosmesis.

27. Bibliography Gurbuz K, Dogar F, Yontar Y. Comparison of Clinical Outcomes of Heterodigital Neurovascular Island Flap, Reverse Homodigital Neurovascular Island Flap, and Cross-Finger Flap Used for Fingertip Reconstruction. Indian J Orthop . 2022 Feb 3;56(5):847-855. Van de Berg WB, Vergeer RA, van der Sluis CK, Ten Duis HJ, Werker P, et al. Comparison of three types of treatment modalities on the outcome of fingertip injuries. Journal of Trauma and Acute Care Surgery. 2012;72:1681–1687. Germann G, Sauerbier M, Rudolf KD, Hrabowski M (2015) Management of thumb tip injuries. J Hand Surg Am 40:614–622 Liu H, Regmi S, He Y, et al. Thumb tip defect reconstruction using neurovascular island pedicle flap obtained from long finger. Aesthetic Plast Surg 2016;40:755-60. Aggarwal K, Singh K. Utility of First Dorsal Metacarpal Artery Flap for Thumb Defects. Indian J Plast Surg. 2022 Dec 22;55(4):368-375. doi : 10.1055/s-0042-1759500. PMID: 36683890; PMCID: PMC9859682. Chitta M, Malathi L, Joseph A. Cross-finger Flap to the Thumb: Quest for an Alternate Donor. Indian J Plast Surg. 2020 Aug;53(2):287-292. doi : 10.1055/s-0040-1714181. Epub 2020 Jul 13. PMID: 32884196; PMCID: PMC7458833. ourabh S. CHAKRABORTY et. Al, A Systematic Review of the Sensory Outcomes of a Standard Cross-Finger Flap Reconstruction for Fingertip Defects. The Journal of Hand Surgery (Asian-Pacific Volume)Vol. 27, No. 05, pp. 782-791 (2022).

28. THANK YOU