Optimizing the Correction of Severe Postburn Hand Deformities by Using Aggressive Contracture Releases and Fasciocutaneous Free-Tissue Transfers

Abstract

Severe postburn hand deformities were classified into three major patterns: hyperextension deformity of the metacarpophalangeal joint of the fingers with dorsal contracture of the hand, adduction contracture of the thumb with hyperextension deformity of the interphalangeal joint, and flexion contracture of the palm. Over the past 6 years, 18 cases of severe postburn hand deformities were corrected with extensor tenotomy, joint capsulotomy, and release of volar plate and collateral ligament. The soft-tissue defects were reconstructed with various fasciocutaneous free flaps, including the arterialized venous flap (n = 4), dorsalis pedis flap (n = 3), posterior interosseous flap (n = 3), first web space free flap (n = 3), and radial forearm flap (n = 1). Early active physical therapy was applied. All flaps survived. Functional return of pinch and grip strength was possible in 16 cases. In 11 cases of reconstruction of the dorsum of the hand, the total active range of motion in all joints of the fingers averaged 140 degrees. The mean grip strength was 16.5 kg and key pinch was 3.5 kg. In palm reconstruction, the wider contact area facilitated the grasping of larger objects. In thumb reconstruction, key-pinch increased to 5.5 kg and the angle of the first web space increased to 45 degrees. Jebsen's hand function test was not possible before surgery; postoperatively, it showed more functional recovery in gross motion and in the dominant hand. Aggressive contracture release of the bone,joints, tendons, and soft tissue is required for optimal results in the correction of severe postburn hand deformities. Various fasciocutaneous free flaps used to reconstruct the defect provide early motion, appropriate thinness, and excellent cosmesis of the hand.

Mutaf procedure: expanding the indications

“…Abnormal scars and contour deformities are of cosmetic concern and lead to physical and functional morbidity, adversely affecting a patient's quality of life [10].…”

The use of reverse-flow dorsal metacarpal artery flaps after postburn metacarpophalangeal joint flexion contracture release

“…It has a constant anatomy and can better match the contours of the hand [7][8][9][10][11]21,22]. As burn reconstruction purpose, reverse-flow DMCA flaps used in thumb, and index finger [23,24]. In our series, we focused on using various reverse-flow DMCA flaps in the four different fingers.…”

Use of an arterialised venous skin flap in the replantation of an amputated thumb

“…Using a venous flap to make up the tissue deficit and to re-establish vascular continuity, as shown by others during the past 20 years, is an effective means of reconstructing deformities of the hands and fingers (2,3,(5)(6)(7)(9)(10)(11). The flap is thin and it is suitable for replacing tissue in the fingers, or hands, or both.…”

“…The thinness of the skin and the ease with which the vascular supplies to the flap were re-established were thought to be the main factors accounted for the usefulness of this flap. Over the past 20 years, many investigators have shared their enthusiasm, particularly in reconstructing hand and finger deformities (2,3,(5)(6)(7)(9)(10)(11).…”