Reoperative Aesthetic & Reconstructive Plastic Surgery

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Tenolysis
Various sources have reported the rate of tenolysis following staged
exor tendon grafting as ranging between 7% and 47%.141,143,158,189 Tenolysis should
not usually be performed until at least 3 months after tendon repair or 6 months af-
ter grafting. Earlier stripping of the soft tissue connections to the tendon graft en-
dangers the circulation of the tendon and increases the risk of rupture, with time
the risk of rupture is decreased. Other preoperative criteria for tenolysis include no
further improvement in the range of motion, an intact exor tendon, supple joints,
a softened scar, healthy skin and a well-motivated patient.191-193 Tenolysis should al-
ways be postponed until as much passive motion is achieved as possible. One should
never expect better active than passive motion, because it does not happen.When
all of the favorable factors are present, 50% to 60% of patients will show improve-
ment following tenolysis. Results are usually best when there are only isolated
(“spot-welded”) sites of adhesions at surgery.
Patients scheduled for tenolysis must be prepared preoperatively for a staged tendon
graft procedure, because it is often dif cult to tell the difference between tendon
ruptures and tendon adhesions. However, sometimes this can be determined on
MRI. Even if the tendon itself is intact, there may be such massive scarring that
tenolysis will not be of bene t. Sometimes it is preferable to use a local anesthetic
so the patient can cooperate during surgery, and the amount of tenolysis needed
can be more easily determined. Lalonde194 used lidocaine (Xylocaine) with epi-
nephrine to do this, which obviates the need for a tourniquet, and he has experi-
enced no complications from epinephrine use in a very large series, refuting the
common belief that epinephrine will cause digital necrosis.
At surgery, an incision is initially made over the volar aspect of the distal forearm
and a exor check is made of the involved tendons. When the procedure is not
performed using local anesthetic, pulling on the involved exor tendon at the level
of the distal forearm will demonstrate when an adequate release of the tendon has
been achieved, and the nger comes to its full passive range of exion.The nger
is approached through the previous incisions, protecting all pulleys or pulley re-
constructions. The tendon is gradually freed from underlying bone as well as the
overlying pulley adhesions, as well as adjacent tendons in the distal forearm. The
carpal tunnel region usually does not need to be opened. Many practitioners add
steroid preparations to the tendon bed following tenolysis.195-199 After the wound is
closed the patient is placed in a bulky dressing for hemostasis and is started in a
program of early active motion under supervision therapy. Some (V.R.M.) also pre-
fer use of the continuous passive motion unit, started immediately after surgery
and at night for 2 weeks. Daytime therapy includes individual joint blocking and
individual nger exion as well as active exion and extension of all ngers to-
gether. Dynamic extension splinting is used if needed during the day and alter-
nated with active range of motion exercises. At 2 weeks postoperatively when the
sutures are removed, scar remodeling techniques are used with massage and ultra-
sound. Graduated resistance exercises are begun four to 6 weeks postoperatively.

Active Prosthetic Tendon Implants
The hope of an active tendon implant has
been repair in one operation without need for a later tendon graft. Pseudosheath
formation does occur and the results of the active and passive implants are compa-
rable as a rst-stage procedure.The difference in the exercise program is that with
active implants the patient’s own muscles provide the necessary motion of the rod
rather than having to monitor passive motion.The rod is made with silicone rub-
ber with a Dacron core and has a proximal loop for proximal exor tendon attach-
ment, and a metal plate for the distal phalanx, usually xed with a screw or Dacron
cords that can be used for distal attachment through drill holes.138 Results are sim-
ilar to the two-stage grafting procedure, with total active motion improving an av-
erage of 72 degrees after insertion of the active rod.200 Complication rates are also
similar, with problems creating a permanent attachment both proximally and dis-
tally. Either juncture may rupture, although rupture at the proximal juncture is most
common.When this occurs, stage II grafting should be performed within 3 weeks.
Most active implants have to be replaced by a tendon graft within 2 years. The
search for a long-term or permanent tendon prosthesis remains elusive.201
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133. Peacock EE. Biological principles in the healing of long tendons. Surg Clin North Am
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134. Potenza AD.Tendon healing within the exor digital sheath in the dog. J Bone Joint Surg Am
44:49-64, 1962.
135. Potenza AD. Prevention of adhesions in healing digital exor tendons. JAMA 187:187-191,
1964.
136. Amadio P. Effect of vincular injury on the results of exor tendon surgery in “no man’s land.”
Presented at the Annual Meeting of the American Academy of Orthopaedic Surgeons,
Atlanta, Feb 1984.
137. Kleinert HE, Steyers CM, Kalisman M. Complications from exor tendon surgery. In Bost-
wick JA Jr, ed. Complications in Hand Surgery. Philadelphia:WB Saunders, pp 19-28, 1986.
138. Schneider LH, Hunter JM. Flexor tendons—late reconstruction. In Green DR, ed. Operative
Hand Surgery, 3rd ed. New York: Churchill Livingstone, 1993, pp 1853-1924.
139. Wilson RL. Flexor tendon grafting. Hand Clin 1:97-107, 1985.
140. Lister G. Pitfalls and complications of exor tendon surgery. Hand Clin 1:133-146, 1985.
141. Amadio PC,Wood MB, Cooney WP III,et al. Staged exor tendon reconstruction in the n-
gers and hand. J Hand Surg Am 13:559-562, 1988.
142. Schneider LH. Injuries to tendons in children. In Bora FW, ed. The Pediatric Upper Ex-
tremity. Philadelphia:WB Saunders, 1986, pp 91-119.
143. Hunter JM, Salisbury RE. Use of gliding arti cial implants to produce tendon sheaths.Tech-
niques and results in children. Plast Recon Surg, 45:564-572, 1970.
144. Pulvertaft RG.Tendon grafts for exor tendon injuries in the ngers and thumb. A study of
technique and results. J Bone Joint Surg Br 38:175-194, 1956.
145. Urbaniak JR, Bright DS, Gill LH, et al.Vascularization and the gliding mechanisms of exor
tendon grafts inserted by the silicone rod method. J Bone Joint Surg Am 56:473-482, 1974.
146. Doyle JR, Blythe WF. The nger exor tendon sheaths and pulleys. Anatomy and recon-
struction. In American Academy of Orthopaedic Surgeons. Symposium on Tendon Surgery
in the Hand. St Louis: Mosby, 1975.
147. Doyle JR, Blythe WF. Anatomy of the exor tendon sheath and pulleys of the thumb. J Hand
Surg 2:149-151, 1977.
148. Brand PW, Cranor KC, Ellis JC.Tendon pulleys at the metacarpophalangeal joint of a nger.
J Bone Joint Surg Am 57:779-784, 1975.
149. Hunter JM, Cook JE. The pulley system: Rationale for reconstruction. In Strickland JW,
Steichen JB, eds. Dif cult Problems in Hand Surgery. St Louis: Mosby, 1982.
150. Solonen KA, Hoyer P. Positioning of the pulley mechanism when reconstructing deep exor
tendons of the nger. Acta Orthop Scand 38:321-328, 1967.
151. Hunter JM, Salisbury RF. Flexor tendon reconstruction in severely damaged hands. A two-
stage process using a silicone Dacron reinforced gliding prosthesis before tendon grafting.
J Bone Joint Surg Am 53:829-858, 1971.
152. Schneider LH. Staged tendon reconstruction using the method of Hunter. Clin Orthop
171:164-171, 1982.
153. Schneider LH. Staged tendon reconstruction. Hand Clin 1:109-120, 1985.
154. Schneider LH. Complications in tendon injury and surgery. Hand Clin 2:361-371, 1986.
155. Wehbe MA, Hunter JM, Schneider LH, et al. Staged tendon reconstruction. Presented at the
Annual Meeting of the American Academy of Orthopaedic Surgeons, Las Vegas, Jan 1985.
156. Hunter JM. Staged exor tendon reconstruction. J Hand Surg 8:789-793, 1983.
157. Bora FW. Profundus tendon grafting with unimpaired sublimis function in children. Clin
Orthop 71:118-123, 1976.
158. Strickland JW. Results of exor tendon surgery in zone II. Hand Clin 1:167-179, 1985.
159. Koch SL. Complicated contractures of the hand. Their treatment by freeing brosed ten-
dons and replacing destroyed tendons with grafts. Ann Surg 98:546-580, 1933.
1933
Chapter 46
Reoperative Hand Surgery

1934
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
160. Boyes JH, Stark HH. Flexor tendon grafts in the ngers and thumb. In Verdan C, ed.Tendon
Surgery of the Hand. Edinburgh: Churchill Livingstone, 1979, p 85.
161. Littler JW. Free tendon grafts in secondary exor tendon repair. Ann J Surg 24:315-321,
1947.
162. Peacock EE. Some technical aspects and results of exor tendon repair. Surgery 58:330-342,
1965.
163. Boyes JH. Operative technique of digital exor tendon grafts. American Academy of Or-
thopaedic Surgeons. Instructional Course Lectures, vol 10. Ann Arbor, MI: JW Edwards,
1953.
164. Tubiana R.Techniques of exor tendon grafts. Hand 1:108-114, 1960.
165. Weiner LJ, Peacock EE. Biologic principles affecting repair of flexor tendons. Adv Surg
5:145-188, 1971.
166. White WL.Tendon grafts. A consideration of their source, procurement and suitability. Surg
Clin North Am 40:402-413, 1960.
167. Pulvertaft RG. Suture materials and tendon junctures. Am J Surg 100:346-353, 1965.
168. Littler JW. The digital exor-extensor system. In Converse JM, ed. Reconstructive Plastic
Surgery, 2nd ed. Philadelphia:WB Saunders, 1977, p 965.
169. Bruner JM. The zigzag volar digital incision for exor tendon surgery. Plast Reconstr Surg
40:571-574, 1967.
170. Urbaniak JB, Cahill JD, Mortenson RA. Tendon suturing methods. Analysis of tensile
strengths. In American Academy of Orthopaedic Surgeons Symposium on Tendon Surgery
in the Hand. St Louis: Mosby, 1975, p 70.
171. Rowland SA. Palmar ngertip use of silicone rubber followed by free tendon graft. In Amer-
ican Academy of Orthopaedic Surgeons Symposium on Tendon Surgery in the Hand.
St Louis: Mosby, 1973, p 145.
172. Osborne GV. The sublimis tendon replacement technique in tendon injuries. J Bone Joint
Surg Br 42:647, 1960.
173. Schneider LH, Hunter JM, Fietti VG.The exor super cialis nger: A salvage procedure. In
Hunter JM, Schneider LH, Mackin EJ, eds. Flexor Tendon Surgery in the Hand. St Louis:
Mosby, 1987, pp 528-532.
174. Chuinard RG, Dabezies EJ, Mathews RE. Two-stage super cialis reconstruction in severely
damaged ngers. J Hand Surg 5:135-143, 1980.
175. Schneider LH, Wiltshire D. Restoration of exor pollicis longus function by exor super -
cialis transfer. J Hand Surg 8:98-101, 1983.
176. Masear VR. Reoperative Hand Surgery. In Grotting JC, ed. Reoperative Aesthetic & Recon-
structive Plastic Surgery, vol II. St Louis: Quality Medical Publishing, 1995, p 1468.
177. Lister GD, Kleinert HE, Katz JE, et al. Primary exor tendon repair followed by immediate
controlled mobilization. J Hand Surg 2:441-451, 1977.
178. Edinburg M, Widgerow AD, Biddulph SL, et al. Early postoperative mobilization of exor
tendon injuries using a modi cation of the Kleinert technique. J Hand Surg Am 12:31, 1987.
179. Jaffe S, Weckesser E. Profundus tendon grafting with the sublimis intact. The end result of
thirty patients. J Bone Joint Surg Am 49:1298-1308, 1967.
180. McClinton MA, Curtis RM,Wilgis EF, et al. One hundred tendon grafts for isolated exor
digitorum profundus injuries. J Hand Surg 7:224-229, 1982.
181. Pulvetaft RG. The treatment of profundus division by the free tendon graft. J Bone Joint
Surg Am 42:1365, 1960.
182. Parker A.The “lumbrical plus” nger. J Bone Joint Surg Br 53:236-239, 1971.
183. Wheeldon T.The use of cellophane as a permanent tendon sheath. J Bone Joint Surg 21:393-
396, 1939.
184. Wilmouth CL.Tendoplasty of exor tendons of the hand. Use of tunica vaginalis in recon-
structing tendon sheaths. J Bone Joint Surg 19:152-156, 1937.
185. Williams CW, Dickie WR, Colville J. Silastic sheeting in hand surgery. Hand 4:273-276,
1972.

186. Suzuki K. Delayed exor tendon repair in the digital sheath with end to end suture and fas-
cial graft. Hand 8:141-144, 1976.
187. Stark H, Boyes JH, Johnson L, et al.The use of paratenon, polyethylene lm or Silastic sheet-
ing to prevent restricting adhesions to tendons in the hand. J Bone Joint Surg Am 59:908-
913, 1977.
188. Nichols HM. Discussion of tendon repair with clinical and experimental data on the use of
gelatin sponge. Ann Surg 129:223-234, 1949.
189. Chamay A,Verdan C, Simonetta C.The two-stage graft:A salvage operation for the exor ap-
paratus (a clinical study of 28 cases). In Verdan C, ed. Tendon Surgery of the Hand. Edin-
burgh: Churchill Livingstone, 1979.
190. LaSalle WB, Strickland JW. An evaluation of the two-stage flexor tendon reconstruction
technique. J Hand Surg 8:263-267, 1983.
191. Weeks PM, Wray RC. Rate and extent of functional recovery after exor tendon grafting
with and without silicone rod preparation. J Hand Surg 1:174-180, 1976.
192. Fetrow KO. Tenolysis in the hand and wrist. A clinical evaluation of two hundred twenty
exor and extensor tenolyses. J Bone Joint Surg Am 49:667-685, 1967.
193. Rank BK, Wake eld AR, Hueston JJ, eds. Surgery of Repair as Applied to Hand Injuries,
4th ed. Baltimore:Williams & Wilkins, 1973.
194. Lalonde D, Bell M, Benoit P, et al. A multicenter prospective study of 3,110 consecutive cases
of elective epinephrine use in the ngers and hand: The Dalhousie Project clinical phase.
J Hand Surg Am 30:1061-1067, 2005.
195. Carstram N. Prevention of experimental tendon adhesions by cortisone. Acta Orthop Scand
22:15-24, 1953.
196. González RH. Experimental tendon repair within the exor tunnels. The use of hydrocor-
tisone without improvement of function of the dog. J Bone Joint Surg Am 35:991-993, 1953.
197. James JIP.The value of tenolysis. Hand 1:118-119, 1969.
198. Whitaker JH, Strickland JW, Ellis KK. The role of exor tenolysis in the palm and digits.
J Hand Surg 2:462-470, 1977.
199. Wrenn RN, Gardner J, Markere J. An experimental study of the effect of cortisone on the
healing process and tensile strength of tendons. J Bone Joint Surg Am 36:588-601, 1954.
200. Hunter JM, Singer DI, Jaeger SH, et al. Active tendon implants in exor tendon reconstruc-
tion. J Hand Surg Am 13:849-859, 1988.
201. Jaeger SH, Hunter JM, Schneider LH, et al. Development of a long-term exor tendon pros-
thesis. In Hunter JM, Schneider LH, Mackin EJ, eds. Flexor Tendon Surgery in the Hand.
St Louis: Mosby, 1986, pp 491-500.
1935
Chapter 46
Reoperative Hand Surgery

1936
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
1. Dense connective tissue structures, such as joint capsule, volar plate and joint
collateral ligaments can be expected to:
a. Have inactive biologic activity
b. Retain their functional activity after immobilization, unless they are di-
rectly ruptured
c. Become lax after injury as a result of in ammatory changes from wound
healing
d. Remodel with less mobility following injury to adjacent structures
e. Should usually be immobilized for 6 weeks if there is any likelihood of
signi cant injury
2. The need for reoperation for recurrent Dupuytren disease can be best explained
by:
a. Genetic predisposition
b. Inadequate excision of Dupuytren bands at the rst operation
c. Inadequate excision of Dupuytren cords at the rst operation
d. Failure to remove the skin overlying the Dupuytren cords using dermato-
fasciectomy and full-thickness skin graft
e. Involvement of the retrovascular cords at the PIP joint
3. Gangrenous ngertip amputation for Raynaud syndrome associated with con-
nective tissue disease should:
a. Be made at a proximal PIP or MP level to permit stump healing
b. Include extended periarterial sympathectomy of the digit as well as adja-
cent digits, distal forearm, wrist, palm and dorsal radial artery
c. Include periarterial sympathectomy of the proper digital arteries in only
the nger involved
d. Await clear demarcation to identify the viable stump tissue
e. Await control of the connective tissue disease with steroid, methotrexate
and calcium channel blocker medication
4. Giant cell tumor of the tendon sheath is characterized as:
a. A benign lesion, easily cured by being certain to remove an adequate por-
tion of the originating tendon sheath
b. A tumor capable of transforming into a malignancy when inadequately
excised
c. Developing a multilobular form from the originating tenocyte
d. Likely recurring in as many as 50% of cases originating from the DIP
joint synovial tissue
e. A benign tumor that is best treated by surgically shelling out its capsule
R EVIEW QUESTIONS

1937
Chapter 46
Reoperative Hand Surgery
5. Tenolysis after exor tendon repair:
a. Is best accomplished by performing surgery within the rst 6 weeks, be-
fore stiffness occurs
b. Is best done early if the patient’s joints are becoming stiff and are losing
range of motion
c. Should never be done using local anesthesia with epinephrine
d. Should not be done if one of the digital nerves does not function
e. Should not be expected to produce better active motion postoperatively
than passive motion available preoperatively

(Trang không có chữ)

1939
Since the rst successful replantation of an amputated thumb by Komatsu and
Tamai in 1965, digit replantation has probably become the single most common
clinical application of microsurgery.1-3 The success rate of digit replantation has im-
proved from less than 50% in early reports to greater than 90% in recent years.4-6 By
the early 1980s clinicians realized that success is not simply measured by survival,
and that function is the real key to this procedure. Therefore, in recent years, the
emphasis has shifted to postreplantation functional outcome rather than viability.
Secondary operations to improve function of the replanted digits and hands have
become an important part of patient management.
Secondary Surgery
Following Digit Replantation
William C. Lineaweaver and Tanya M. Oswald
C ha pter 4 7
Reoperative Problems
Soft tissue loss
Joint contracture
Poor sensation
Soft tissue contraction
Skeletal nonunion or deformity
Tendon adhesion and rupture
For let our nger ache, and it endues [brings]
Our other healthful members even to a sense of pain.
William Shakespeare

1940
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
The incidence of secondary surgery after successful nger/ hand replantation varies
from 2.6% to 92%.4-20 Secondary operations are almost always necessary after limb
replantation.These operations include major ap procedures for coverage, correc-
tive osteotomy, bone grafting, release of joint, muscle and skin contractures, nerve
grafting, tendon or muscle transfer, tenolysis, free neurotized muscle transfer, and
below elbow limb amputation.21,22
Digit replantation distal to the super cialis tendon insertion rarely re-
quires further reconstruction.
Patradul et al6 reported only 5 secondary bone grafts for nonunion arthrodesis of the
DIP joint in distal digital replantation and revascularization of 237 digits in 192 pa-
tients. Secondary operations after digit replantation can include skin, tendon, bone,
joint, and nerve procedures.* These operations are most commonly performed be-
cause of stiffness of the replanted digit.Among the types of secondary operations,the
Incidence of Secondary Surgery After Successful Digit Replantation
Number of
Number of Patients
Number
Secondary
W ith Secondary
Author
of Patients
Procedures
Procedures
Weiland et al4 (1977)
32
20
20 (62%)
Morrison et al7 (1977)
100
22
14 (14%)
Tamai8 (1978)
97
34
29 (30%)
Schlenker et al9 (1980)
46
20
12 (26%)
Scott et al10 (1981)
38
53
30 (79%)
Pitzler, Buck-Gramcko11 (1982)
106
104
49 (46%)
May et al12 (1982)
18
1
1 (5.6%)
Russell et al13 (1984)
30
43
16 (53%)
Meyer14 (1985)
105
57
24 (23%)
Urbaniak et al15 (1985)
51
26
15 (29%)
Buncke and Whitney16 (1991)
157
221
94 (60%)
Goldner et al17 (1990)
69
1
29 (42%)
Caroli et al18 (1991)
18
15
11 (61%)
Weinzweig et al19 (1996)
12
49
11 (92%)
Yildiz et al20 (1998)
22
4
4 (18%)
Patradul et al6 (1998)
192
5
5 (2.6%)
Waikakul et al5 (2000)
508
460
180 (35%)
TOTAL
1601
1135
544 (34%)
*References 4, 5, 8-12, 14, 15, 18-20, 23-25.

1941
Chapter 47
Secondary Surgery Following Digit Replantation
Incidence of Various Types of Postreplantation Surgery
Number of
Author
Procedures
Skin
Skeleton
Nerve
Joint
Tendon
Amputation
Weiland et al4 (1977)
20
0
0
11
0
9
0
Morrison et al7 (1977)
47
0
0
16
3
25
3
Tamai8 (1978)
34
0
9
7
4
14
0
Schlenker et al9 (1980)
20
3
2
3
2
9
1
Scott et al10 (1981)
51
7
1
5
13
25
0
Tamai23 (1982)
98
24
18
13
20
23
0
Pitzler and Buck-Gramcko11 (1982)
104
27
9
20
18
30
0
May et al12 (1982)
1
1
0
0
0
0
0
Meyer14 (1985)
57
13
7
11
6
20
0
Urbaniak et al15 (1985)
26
0
4
2
9
9
2
Steichen24 (1987)
55
0
0
0
19
36
0
Tark et al25 (1989)
46
31
2
0
1
6
6
Caroli et al18 (1991)
15
7
3
1
1
3
0
Weinzweig et al19 (1996)
49
2
6
2
11
28
0
Yildiz et al20 (1998)
4
0
1
0
0
2
1
Waikakul et al5 (2000)
460
NA
69
NA
76
275
0
TOTAL
1087
115
131
91
183
514
13
(11%)
(12%)
(8.4%)
(17%)
(47%)
(1.2%)
incidence of tendon surgery is the highest (45.8%), followed by operations for joint
mobility and position (18.3%).Soft tissue reconstruction (11.4%) and nerve grafting
(8.6%) represent other common secondary procedures. The rate of amputation is
only 1.3%. A combination of sensory,7,9,15 joint, and tendon malfunction, and rarely
infection20,25 usually contribute to the necessity of late amputation.
PATIENT EDUCATION, TIMING,
AND PREOPERATIVE PLANNING
The probability of a secondary operation should be included in the initial discus-
sion of replantation with patients who are referred for the emergency treatment of
an amputation. Except for patients with distal digit replantation, the chance of
needing more operations to achieve useful function in their replanted ngers is
30% to 50% for most patients. Some of these patients may at this point decide to
proceed with completion of amputation.

1942
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
If the patient decides to undergo replantation, the patient and the sur-
geon must have a clear understanding of the anticipated immediate
outcome, probable future operations, postoperative recuperation and
therapy, as well as realistic expectations about the future function.
When it comes to secondary surgery, the patient should be well-informed, realis-
tic, and motivated. At each stage of the reconstruction process, the patient and sur-
geon should reevaluate the patient’s level of function.The decision regarding future
operations should be made with the realization that there is a small but real chance
of loss of the replanted nger after repeated surgery.This discussion must be frank
with each patient.
When secondary surgery in the replanted digit is being planned, it is crucial to ob-
tain detailed records of the original replantation procedure.The location of arterial,
venous, and nerve repairs, tendon involvement, as well as unusual components such
as a vein graft crossing over a exor tendon, must be carefully reviewed to prevent
damage during reoperation. Knowledge of the location of these initial repairs can
also in uence placement of the incision.
Another key element in planning for secondary surgery is the sequence in which
the procedures will be performed. Before any further reconstruction can take place,
stable and supple skin coverage must be achieved. The next priorities should be
skeletal stabilization and alignment.These procedures can be performed at the same
time that the skin is reconstructed. Secondary nerve repair or nerve grafting can
also be performed at the same time as skin and skeletal reconstruction, as long as the
dissection for exposure is not too extensive and skin coverage is secure. It would be
unwise to perform tenolysis at this time, because postoperative immobilization is re-
quired after major skin, skeletal, and nerve repairs, and early motion is usually op-
Preconditions and Postoperative Requirements for Postreplantation
Secondary Procedure
Necessary Preconditions
Postoperative Requirements
Skin
Viability of replanted nger
Immobilization
Edema control
Skeleton
Stability of skin coverage
Immobilization
Edema control
Nerve
Stability of skin and skeleton
Immobilization
Joint
Stability of skin and skeleton
Passive/active mobilization
Proprioception
Tendon
Stability of skin and skeleton
Passive/active mobilization
Proprioception
Supple joint

timal therapy after tenolysis. Joint reconstruction, either by capsulotomy or arthro-
plasty, should follow these procedures because it requires skin coverage, skeletal sta-
bility, and protective and proprioceptive sensation to maximize the chance for func-
tional success. Finally, tendon reconstruction, including grafting, tenolysis, and
transfer, are best attempted after joint reconstruction and its preconditions have
been completed.
Constant communication between the patient, hand therapist, and surgeon is
needed to evaluate and update the recovery process. The goals of the operation
should be speci c and clear.
In a multicomponent operation, the therapy plan should be discussed
with the hand therapist to avoid mutually incompatible postoperative
rehabilitation requirements.
The timing of secondary surgery is determined primarily by the progress in ther-
apy. For the initial secondary surgery, it is best to wait until the nerve, joint, and ten-
don function are stable and skin coverage is secure. Usually this interval is 3 to 6
months after replantation.8,23 Bone malunion or nonunion, which may hinder ther-
apy and hand function, should be corrected once it is recognized.26
SECONDARY SURGICAL PROCEDURES
Most aspects of reconstructive surgery unique to digit replantation concern pa-
tient selection, timing, and preoperative planning.The surgical techniques for sec-
ondary procedures themselves generally do not vary greatly from descriptions avail-
able in current hand surgery texts.27,28 The most frequently performed secondary
operations after digit replantation are discussed below.The necessary preconditions
and postoperative requirements of different categories of secondary surgery are
listed on p. 1942.
SKIN R ECONSTRUCTION
Skin Grafting for Small Defects
Areas of marginal necrosis frequently develop at the suture line. Although these ar-
eas may heal spontaneously with local wound care, skin grafting should be consid-
ered in an open wound larger than 1 cm2, because secondary wound healing may
cause a contracture compromising a joint or a web space.The damaged skin should
be excised. Full-thickness skin grafts are preferred because they undergo less con-
tracture than split-thickness skin grafts.28 The grafts should be carefully defatted
into the dermal layer and fixed to the contour of the defect with 5-0 or 6-0
chromic sutures. A donor site remote from the injured extremity is preferred so
that pain or donor site complication would not add further insult to the recovery
of the injured extremity. Care should be taken not to damage any underlying mi-
crovascular repair. Digit mobilization can be resumed within 3 to 4 days.
1943
Chapter 47
Secondary Surgery Following Digit Replantation

1944
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
Web Space Releases
Soft tissue scarring and contracture at the web space can occur after digit replan-
tation at the level just distal to the web space. If the contracture is small and the dor-
sal and volar skin is supple, a Z-plasty with transposition of the aps is used to re-
lease the contracture.
However, if the defect is larger and there is only one adjacent plane of supple skin,
a YV advancement ap technique should be employed. A small triangular inci-
sion is made in the web space using the supple skin to create a ap. In a situation
with a larger defect with inadequate adjacent tissue for potential coverage, the scar
tissue should be excised and the defect resurfaced with a full-thickness skin graft.

In releasing the rst web space in this example, the dorsal index nger ap is har-
vested. The ap is transposed to the open rst web space. The defect on the dor-
sum of the index nger is covered with skin graft.
Correction of Volar Joint Contracture
1945
Chapter 47
Secondary Surgery Following Digit Replantation
Y extension
Replantation
scar
Y extension
Full-thickness
skin graft
Flexion contracture can occur at the proximal interphalangeal joint solely as a con-
sequence of skin contracture. In releasing the contraction, a Brunner-type incision
should be used.The replantation scar should be incorporated into the incision.The
incision de nes the aps to be raised, permitting capsulotomy as necessary.Y exten-
sions are made at the tip of each V incision along the replantation scar dorsally,
opening up limbs to accommodate advancement of the skin aps. This advance-
ment typically leaves a small open wound with adequate subcutaneous tissue prox-
imal to the aps. This defect can be resurfaced with a full-thickness skin graft or
with a thin, pliable rst web space ap from the foot in case of progressive volar
scarring.29

1946
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
SKELETAL R ECONSTRUCTION
Secondary reconstruction of skeleton should be performed after stable skin cover-
age is achieved. Nonunion repair, bone graft, and corrective osteotomy are dis-
cussed here.
Repair of Nonunion
The rate of nonunion depends on the zone and mechanism of injury, as well as
xation methods used.The use of Kirschner wire is one of the reliable, simple x-
ation techniques.26 The rate of nonunion after a crush injury in zone II is 15%.30
The nonunion can be recognized immediately after removal of a Kirschner wire 4
to 8 weeks after replantation.The nonunion can sometimes be healed with splint-
ing, but it may be best to operate on these failures because stable bone xation can
reduce splinting time and facilitate therapy to generate better functional outcome.
The nonunion can be approached by a dorsal skin incision over the area of defect.
The extensor tendon is split with a longitudinal incision.The dorsal vein may not
be spared by this approach. However, if the dissection does not extend too exten-
sively into the volar area, vascular compromise can be avoided because of dermal
circulation that has developed across the wound. All brous tissues, nonviable bone,
bony irregularities, and tendon intrusions are removed. If the two ends of the re-
maining bone are healthy, they can be joined with a Kirschner wire as long as the
wire does not cross a joint. If the wire must cross a joint, the two ends of the bone
may be joined by a small plate or an interosseous wire.
Bone Grafts
If the resection of a nonunion results in unacceptable shortening of a digit, a bone
graft is indicated. The bone may be harvested from the fth or sixth ribs. The rib
segments are excellent sources because they can be shaped to ll in irregular defects
with good cortical contacts.
An S-shaped dorsal incision, incorporating the replantation scar,
is used for maximum exposure.

1947
Chapter 47
Secondary Surgery Following Digit Replantation
The extensor mechanism is incised longitudinally to expose the bony structure.
After debridement of an unstable brous nonunion, the rib segment is used to ll
the defect. Either a Kirschner wire, a plate, or an interosseous wire can be used for
xation. A miniplate is used to x the phalanx and the bone graft in the illustrated
example.
CORRECTIVE O STEOTOMY
The replanted nger may heal with angular, rotational, or a combination of angu-
lar-rotational deformities as a consequence of poor primary bone union, postoper-
ative shift or instability, bony resorption, or reinjury. Corrective osteotomy is per-
formed to correct such angulations or to reduce the rotation. The malunion may
interfere with motion of the digit, and the deformity should be corrected after ad-
equate sensation in the replanted digit is established.The healed fracture is exposed
with a dorsal incision, followed by splitting of the extensor mechanism. The frac-
ture is incised with a sidecutting saw to remove angulated bone, leaving only well-
matched bone ends. If the original fracture site is too complicated or the soft tis-
sue coverage at this site is not available, corrective osteotomy may be performed at
a more proximal site. For example, the metacarpal may be rotated.This reposition-
ing should be performed with care, because even if the replanted nger may be
straight, mechanical defects can develop in the tendon and joint structure with time.

1948
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
NERVE R ECONSTRUCTION
Nerve reconstruction should be undertaken only after skin coverage and skeletal
stability have been established. Nerve reconstruction is indicated in patients with
poor sensation after a digital nerve repair. Secondary nerve reconstruction proce-
dures include neurolyses, neurorrhaphies, or interpositional nerve grafts.
In these procedures, it is important to note that the neurovascular bun-
dles may not be in the usual anatomic position.
Bone shortening and disruption of the compartment formed by Grayson’s and Cle-
land’s ligaments can displace the neurovascular bundles.The neurovascular bundles
may be encased in scar tissues. The original notes of the replantation must be re-
viewed with particular attention to any unusual revascularization procedures (for
example, vein grafts crossing the digit from one digital artery to the other).To safely
identify structures, dissection should begin proximally in a relatively undamaged
soft tissue area, proximal to the level of replantation. The neurovascular bundles
then can be traced distally.
Neurolysis
Neurolysis of the digital nerves can signi cantly improve poor but measurable sen-
sation.This procedure can be performed simultaneously with exor tenolysis.The
nerve should be carefully inspected to ensure that no nerve resection or recon-
struction is required before performing the tenolysis.
Neurectomy, Primary Repair, and Nerve Grafts
If waxy, scarred nerves with gross loss of fascicular con guration or neuroma-in-
continuity is found intraoperatively, the grossly abnormal nerve segment should be
resected and repaired, if possible, by direct neurorrhaphy. If primary repair is not fea-
sible, such as when primary nerve gaps exist from the time of primary replantation
or after a signi cant length of damaged nerve resection, nerve grafts should be used.
The dimension of the nerve defect should be determined before har-
vesting the nerve graft.
Sural nerve, which is consistently larger than the digital nerves, is a good source for
nerve grafting. Its larger dimensions allow complete enclosure of both digital nerve
ends into the graft ends.The patient can be placed in a lateral decubitus position to
facilitate reexploration of the replanted digit and sural nerve harvest. Although
there are reports of using various conduits to bridge the nerve defect or of attempts
to use vascularized nerve grafts31 in postreplantation surgery, sural nerve grafting
remains the most widely used procedure.32

JOINT R ECONSTRUCTION
Secondary joint reconstruction is considered only after secure skin coverage, stabi-
lization of skeletal structures, and establishment of adequate proprioceptive sensa-
tion. Secondary procedures used to reconstruct the joints after digital replantation
include capsulotomy, capsuloplasty, arthrodesis, and arthroplasty.
Capsulotomy
Capsulotomy is exclusively performed for the proximal interphalangeal joint con-
tractures. Distal interphalangeal joints respond poorly to capsulotomy in general,
and metacarpophalangeal joints rarely result in contracture. Analysis is necessary to
isolate dorsal and volar components of the contracture before the procedure. Only
one side of the replanted digit, either volar or dorsal, should be explored in a given
setting to avoid circulatory disruption.
1949
Chapter 47
Secondary Surgery Following Digit Replantation
In dorsal capsulotomy, a wide exposure and mobilization of the extensor mecha-
nism and the dorsal hemisphere of the joint capsule, including the radial and ulnar
collateral ligaments, are required. The dorsum of the joint capsule is sharply ex-
cised. The extensor hood is completely mobilized. Extensor tenolysis may be ex-
tended proximally to release any adhesions of the extensor mechanism to the joint,
fracture site, intrinsic slip, and skin. Intrinsic releases can be considered if scar exci-
sion alone does not relieve intrinsic tightness.

1950
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
If the volar component is deemed responsible for the contracture, a volar capsulo-
tomy is performed using a zigzag volar incision, which can be modified to YV
aps.33 The likelihood of abnormal position of the neurovascular bundles, again,
should be kept in mind to avoid inadvertent injury. A wide exposure is required to
allow better identi cation of the digital arteries and nerves.The exor tendon sheath
is opened over the joint. Tenolysis of the profundus tendon is performed, if indi-
cated.The profundus tendon is then retracted laterally to expose the super cialis in-
sertion and the volar aspect of the joint. The contracted super cialis remnant, if
found, may be excised. The volar plate, which is usually diffusely thickened and
the checkrein ligaments obscured, can be released.The volar plate is incised at the
level of the proximal phalangeal condyles as laterally as possible to allow full exten-
sion of the joint. Following this, a dorsal splint is applied to prevent hyperextension.
Capsuloplasty
In patients with a signi cant deformity because of elongation of the injured tendon
such as swan neck, mallet, and intrinsic minus deformities,8 capsuloplasty is indi-
cated. One common deformity is hyperextension of the proximal interphalangeal
joint in patients whose level of replantation is at the proximal interphalangeal joint,
who have gained active extension and good passive range of motion at the proxi-
mal interphalangeal joint.

In these patients, a YV advancement ap can be performed to shorten the exor
tendon. The Y incision is made on the volar plate and is converted to a V ap,
thereby shortening the volar plate and correcting the hyperextension in conjunc-
tion with a functioning exor tendon.
Arthrodesis
Arthrodesis may be necessary if the exion deformity cannot be corrected with
tenolysis or capsulotomy in the case of a thumb, or if there is trauma involving the
joint during replantation. Arthrodesis is performed with a dorsal exposure. The
joint is resected, and a Kirschner wire is used to x the digit in about 10- to 15-de-
gree exion.The slight angulation seems to enhance pulp-to-pulp contact without
much noticeable deformity. If inadequate pulp is present or if the distal phalanx is
insensate, amputation should be considered.
Arthroplasty
Arthroplasty using silicone joint prostheses can produce functional results at the
metacarpophalangeal joint or the proximal interphalangeal joint.24,34 The prosthe-
sis can be used to replace the arthrodesis.The standard Swanson implant technique
can be used in these cases.35
Because there is no dorsal capsule to close over the implant, special
care must be taken to position the implant into the bone and recenter
the extensor mechanism.
Even then, stability may still be a problem because many replants lack stabilizing
structures of the joint after trauma. A two-piece unconstrained replacement pros-
thesis that is inserted with minimal bony excision and optimum preservation of
the collateral ligaments may offer a more stable joint.36
1951
Chapter 47
Secondary Surgery Following Digit Replantation

1952
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
TENDON R ECONSTRUCTION
Tendon procedures can only be performed after the skin, nerve, and joint func-
tions have been restored. Tenolysis, tendon grafting, and pulley reconstruction are
discussed here.
Tenolysis
Extensor tenolysis is restored rst when the replanted digit is limited in its active
and passive range of motion. An S incision incorporating the replantation scar is
made dorsally. If the range of motion remains incomplete after the extensor tenol-
ysis, dorsal capsulotomy is included. After rehabilitation has reached its plateau in
approximately 6 weeks, and if the active range of motion is still signi cantly less
than the passive range of motion, exor tenolysis is performed through a Brunner
incision. The exor tendon is then released. Whenever it is possible, the annular
pulley or its scar remnant must be preserved.
Tendon Grafting
If the tendon is ruptured, markedly attenuated, bridged with scar tissue, or thinned
out after tenolysis, staged tendon reconstruction should be performed. After de-
bridement, a silicone tendon rod is placed to establish a pseudosheath for tendon
grafting at a later date.These procedures are generally the same as procedures used
in nonreplanted digits.37-39 The largest possible size silicone rods (2 to 4 mm) that
will permit tension-free skin closure should be used.
The rod is tucked beneath the distal end of the tendon, distal to the proximal in-
terphalangeal joint.The rod is sutured into place using nonabsorbable mattress su-
tures with the suture knots tied beneath the rod. The proximal end of the rod is
tunneled and is left free in the palmar space.

In 10 to 12 weeks, after the overlying tissue has regained its suppleness, the tendon
grafts can be placed. The extensor tenolysis and tendon grafting are performed
with the same general principle. In reconstructing the extensor, the distal end of the
rod should be sutured to the extensor hood of the proximal interphalangeal joint.
Pulley Reconstruction
Successful replantation depends not only on the tendon function, but also on the
function of the pulley structures.The second annular pulley is often damaged by ei-
ther the original amputation or subsequent tenolysis, creating bow-stringing of the
exor tendon and loss of its function. Pulley reconstruction techniques vary.40,41 The
procedures may be approached through the same incision for exor tenolysis,tendon
rod insertion, and volar capsulotomy to reduce the risk of vascular compromise.
1953
Chapter 47
Secondary Surgery Following Digit Replantation
One method of reconstructing a pulley involves mobilization of a slip of the super-
cialis insertion, which is swung across the profundus tendon or the tendon rod.
The mobilized super cialis can be sutured to the other border of the super cialis
tendon to create a proximal phalangeal pulley.37
If the super cialis tendon has been resected during the original re-
plantation but there is a long enough tail left, this remnant may be
used to create a pulley in the A3 area. The free end of the tail, with
its insertion intact, is mobilized across the profundus tendon or the
tendon rod and is sutured to the periosteum or the rim of the pul-
ley remnant on the opposite side.

1954
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
AMPUTATION
Reamputation, though rarely reported in replanted digits, may sometimes be a log-
ical choice in cases of unsalvageable infection, recalcitrant scar tissue contracture,
joint destruction, or poor sensation.
The possibility of amputation must be discussed with the patient dur-
ing the initial presentation of replantation and throughout the course
of reconstruction.
Late amputations are performed just proximal to the most proximal stiff joint.The
stump can be adapted to accommodate a digital prosthesis, which can result in psy-
chological and social bene t to the patient. If the index nger is amputated at the
proximal interphalangeal joint, the remaining stump may make a thumb pinch be-
tween the thumb and the long nger dif cult. If the long nger and the ring n-
ger are amputated too proximally, a defect is created in the transverse palmar arch
through which an object may be dropped. Furthermore, the remaining ngers may
deviate medially on exion because of the absence of the long and ring ngers. In
these situations, a ray amputation may be considered though it must be kept in
mind that this technique can result in palm narrowing and reduction of grip
strength.42
COLD INTOLERANCE
Cold intolerance or cold insensitivity is a problem in almost all patients after replan-
tation.* In a cold environment the replanted digit becomes blue and painful to a
varying degree.This is a poorly understood condition and it is unclear to what ex-
tent it is caused by vascular or neurologic phenomena. Freelander43 found no clear-
cut relationship between cold intolerance and two-point discrimination, cutaneous
blood ow, and vasomotor activity. Although cold insensitivity has been shown to
improve with time after 1 to 2 years,some recent studies,in contrast to previous nd-
ings, indicate that cold symptoms do not decrease with the passage of time.4,7,44-46
Microsurgical attempts have been made to relieve both diminished sensation and
autonomic dysfunction. Hussl et al47 reported implantation of the thoracodorsal
vascular bundles in four replanted ngers. The thoracodorsal artery was anasto-
mosed in an end-to-side fashion in the radial fossa, and the concomitant veins were
anastomosed in an end-to-end fashion.The bundles were tunneled under the skin
to the ngertip. The ngertip defect was covered with a split-thickness skin graft.
At a 11⁄2-year follow-up, the vascular bundles were patent as con rmed by Doppler
examination, and improvement in cold intolerance and trophic disturbance were re-
ported in all patients. Schwabegger et al48 reported similar results using the serratus
fascia ap pedicled on the thoracodorsal or the serratus branch.
*References 4, 7, 8, 15, 17, 23.

POSTOPERATIVE CARE AND R EHABILITATION
Hand therapy plays a critical role in all aspects of care after nger replantation. A
comprehensive postoperative plan, including splinting, injury-speci c mobilization
protocols, and therapy site, is developed immediately after surgery. After discharge,
the patient is followed closely during hand therapy for monitoring of wound heal-
ing, supervision of therapy programs, and evaluation of functional progress. The
patient’s demands should also be coordinated to meet both occupational and voca-
tional requirements.The recovery process is documented and updated.This will as-
sist in identifying the need as well as timing of future secondary operations.
PATIENT EXAMPLES
1955
Chapter 47
Secondary Surgery Following Digit Replantation
This radiograph shows the replantation level of the little nger of a 28-year-old pa-
tient who had sustained a saw injury of the left hand. Emergency surgery consisted
of full-thickness skin grafting of the thumb pulp; revascularization, exor repair,
and digital nerve repair of the index nger; ulnar digital nerve repair of the mid-
dle nger; digital nerve repair of the ring nger; and replantation of the little n-
ger at the level of the midproximal phalanx.
Six months later, after good return of sensation and joint mobility, the patient un-
derwent tenolysis and annular pulley reconstruction of the index nger, as well as
exor tenolysis of the little nger. Local scar tissue was used to reconstruct the pul-
ley.Two months later, the exor to the little nger ruptured and a tendon rod was
inserted. A tendon graft was performed 12 weeks later.

1956
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
One year later, the patient shows full extension and can ex all ngers to the palm.
The total active range of motion is 210 degrees for the index nger and 150 de-
grees for the little nger.
When a 23-year-old patient sustained a crush injury to the left hand, emergency
surgery was performed to replant the index nger and revascularize the middle,
ring, and little ngers, all at the level of the web spaces. Seven months later, the pa-
tient underwent exor tenolysis and exion improved in all ngers except the mid-
dle nger.Fifteen months after the injury the patient had poor sensation of the mid-
dle and ring ngers, a contracture of his third web space, and lack of exion of his
middle nger.The patient underwent Z-plasty release for the web space,nerve graft-

ing to previously unrepaired nerves to the middle and ring ngers, and replacement
of a exor tendon rod from the middle nger to the palm. Postoperatively the mid-
dle nger was immobilized for 4 weeks;then passive range of motion exercises were
started. Ten weeks after rod placement, the patient underwent tendon grafting. A
year after this procedure, the distal phalanx of the index nger was fused because of
a persistent exion deformity,and volar capsulotomies were performed on the prox-
imal interphalangeal joints of the middle and ring ngers. Sixteen months later,
proximal interphalangeal joint capsulotomies were performed again. One year post-
operatively the patient had protective sensation in all ngers and was employed in
engine rebuilding. Full extension is still hampered by 20-degree exion contrac-
tures of the proximal interphalangeal joints of the patient’s middle and ring ngers.
The fused index nger is stable, and the patient has active exion to the palm.
1957
Chapter 47
Secondary Surgery Following Digit Replantation
These radiographs show the level of amputation of middle and ring ngers and
the level of replantation of the index nger of a 31-year-old patient. All ngers
were replanted—the index nger at the level of the middle phalanx, and the ring
and middle ngers at the level of the midproximal phalanges. A proximal second
level laceration required repair of the extensor hood and the metcarpophalangeal
joint capsule of the index nger. Six months later, with good return of sensation,
an extensor tenolysis and metacarpophalangeal joint capsulotomy were performed
on the index nger, with good resultant fusion.

1958
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
Three months later, the patient underwent exor tenolysis of the ring nger and
placement of a tendon rod in the middle nger and palm. The rod was replaced
with a graft 12 weeks later, and a contracture of the third web space was relieved
with a YV ap. Eighteen months later, the patient had full extension, preservation
of the web space, and exion to the palm.
References—With Key Annotated References
1. Komatsu S,Tamai S. Successful replantation of a completely cut-off thumb. Case report. Plast
Reconstr Surg 42:374, 1968.
2. Biemer E, Duspiva W. Reconstructive Microvascular Surgery. London: Springer-Verlag, 1982,
p 97.
3. O’Hara M, Lineaweaver W. Microsurgical replantation: Development and current status. Crit
Care Nurs Q 13:1, 1990.
4. Weiland AJ,Villarreal-Rios A, Kleinert HE, et al. Replantation of digits and hands. Analysis of
surgical techniques and functional results in 71 patients with 86 replantations. J Hand Surg
2:1, 1977.
5. Waikakul S, Sakkarnkosol S,Vanadurongwan V, et al. Results of 1018 digital replantations in 552
patients. Injury 31:33, 2000.

6. Patradul A, Ngarmukos C, Parkpian V, et al. Distal digital replantations and revascularizations:
237 digits in 192 patients. J Hand Surg Br 23:578, 1998.
7. Morrison WA, O’Brien BM, Macleod AM. Evaluation of digital replantation:A review of 100
cases. Orthop Clin North Am 8:295, 1977.
8. Tamai S. Analysis of 163 replantations in an 11-year period. Clin Plast Surg 5:195, 1978.
9. Schlenker JD, Kleinert HE,Tsai TM. Methods and results of replantation following traumatic
amputation of the thumb in 64 patients. J Hand Surg 5:63, 1980.
10. Scott FA, Howard JW, Boswick JA. Recovery of function following replantation and revascu-
larization of amputated hand parts. J Trauma 21:204, 1981.
11. Pitzler D, Buck-Gramcko D. Secondary operations after replantation. Ann Chir Gynaecol
71:19, 1982.
12. May JW,Toth BA, Gardner M. Digital replantation distal to the proximal interphalangeal joint.
J Hand Surg 7:161, 1982.
13. Russell RC, O’Brien BM, Morrison WA, et al.The late functional results of upper limb revas-
cularization and replantation. J Hand Surg Am 9:623, 1984.
14. Meyer V. Upper extremity replantation, basic principles, surgical technique and strategy. New
York: Churchill Livingstone, 1985, p 96.
15. Urbaniak JR, Roth JH, Nunley JA, et al.The results of replantation after amputation of a sin-
gle nger. J Bone Joint Surg Am 67:611, 1985.
16. Buncke HJ,Whitney TM. Secondary reconstruction after replantation. In Buncke HJ, ed. Mi-
crosurgery:Transplantation-Replantation: An Atlas Text. Philadelphia: Lea & Febiger, 1991, p
651.
17. Goldner RD, Howson MP, Nunley JA, et al. One hundred eleven thumb amputations: Re-
plantation vs revision. Microsurgery 11:243, 1990.
18. Caroli A, Adani R, Castagnetti C. Replantation and revascularization of large segments of the
hand and forearm. Ital J Orthop Trauma 17:433, 1991.
19. Weinzweig N, Sharzer LA, Starker I. Replantation and revascularization at the transmetacarpal
level: Long-term functional results. J Hand Surg Am 21:877, 1996.
This article presents a thorough scheme for evaluating function after replantation.
20. Yildiz M, Sener M, Baki C. Replantation in children. Microsurgery 18:410, 1998.
21. Wood MB, Conney WP. Above elbow limb replantation: Functional results. J Hand Surg Am
11:682, 1986.
22. Daoutis N, Gerostathopoulos N, Bouchlis G, et al. Clinical analysis and evaluation of the func-
tion of replanted and revascularized parts of the upper limb. Microsurgery 13:178, 1992.
23. Tamai S. Twenty years’ experience of limb replantation: Review of 293 upper extremity re-
plants. J Hand Surg 7:549, 1982.
24. Steichen JB. Management of exor tendon injury associated with digital replantation or revas-
cularization. In Hunter JM, Schneider LH, Mackin E, eds. Tendon Surgery of the Hand. St
Louis: Mosby, 1987, p 156.
25. Tark KC, Kim YW, Lee YH, et al. Replantation and revascularization of hands:Clinical analy-
sis and functional results of 261 cases. J Hand Surg Am 14:17, 1989.
26. Whitney TM, Lineaweaver WC, Buncke HJ, et al. Clinical results of bony xation methods in
digital replantation. J Hand Surg Am 15:328, 1990.
27. Jupiter JB. Flynn’s Hand Surgery, 4th ed. Baltimore:Williams & Wilkins, 1991, p 211.
28. Rudolph R, Ballantyne DL. Skin grafts. In McCarthy J, ed. Plastic Surgery. Philadelphia:WB
Saunders, 1990, p 221.
29. Tseng O,Tsai YC,Wei FC, et al. Replantation of ring avulsion of index, long, and ring ngers.
Ann Plast Surg 36:625, 1996.
30. Buncke HJ, Buncke GM, Kind GM, et al. Replantation, revascularization and toe-to-hand
transplantation. In Goldwyn RM, Cohen MN, eds.The Unfavorable Result in Plastic Surgery:
Avoidance and Treatment, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2001, p 785.
These authors have experienced much of the history of replantation.Their analysis of unfavorable re-
sults usefully illustrates strategies of secondary procedures after replantation.
1959
Chapter 47
Secondary Surgery Following Digit Replantation

1960
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
31. Rose EH, Kowalski TA, Norris MS. The reversed venous arterialized nerve graft in digital
nerve reconstruction across scarred beds. Plast Reconstr Surg 83:593, 1989.
32. Millesi H.The current state of nerve microsurgery. In Reidiger D, Ehrenfeld M, eds. Microsur-
gical Tissue Transplantation. Chicago: Quintessence, 1989, p 159.
33. Watson HK,Turkeltaub SH. Stiff Joints. In Green DP, ed. Operative Hand Surgery, vols 1 to 3,
2nd ed. New York: Churchill Livingstone, 1988, p 537.
34. Buncke GM, Buncke HJ, Kind GM, et al. Replantation. In Russell RC, ed. Plastic Surgery:In-
dications, Operations, and Outcomes, vol 4, Hand Surgery. St Louis: Mosby, 2000, p 2131.
This recent textbook chapter gives a good overview of indications and techniques of replantation, as
well as an analysis for approaching later problems.
35. Swanson AB, Swanson GG. Flexible implant resection arthroplasty in the upper extremity. In
Jupiter JB, ed. Flynn’s Hand Surgery, 4th ed. Baltimore:Williams & Wilkins, 1991, p 342.
36. Linscheid RL, Murray PM,Vidal MA, et al. Development of a surface replacement arthroplasty
for proximal interphalangeal joints. J Hand Surg Am 22:286, 1997.
37. Schneider LH, Hunter JM. Flexor tendon: Late reconstruction. In Green DP, ed. Operative
Hand Surgery, vols 1 to 3, 2nd ed. New York: Churchill Livingstone, 1988, p 1969.
38. Kleinert H, Smith RI, Pulvertaft RG. Flexor tendon grafting in the hand. In Jupiter JB, ed.
Flynn’s Hand Surgery, 4th ed. Baltimore:Williams & Wilkins, 1991, p 283.
39. Hunter JH, Aulicino PL. Salvage of scarred tendon systems using passive and active Hunter ten-
don implants. In Jupiter JB, ed. Flynn’s Hand Surgery, 4th ed. Baltimore:Williams & Wilkins,
1991, p 300.
40. Widstrom CJ, Johnson G, Doyle JR, et al. A mechanical study of six digital pulley reconstruc-
tion techniques. I. Mechanical effectiveness. J Hand Surg Am 14:821, 1989.
41. Widstrom CJ, Johnson G, Doyle JR, et al. A mechanical study of six digital pulley reconstruc-
tion techniques. II. Strength of individual reconstruction. J Hand Surg Am 14:826, 1989.
42. Louis DS, Jebson PJ,Graham TJ. Amputations. In Green DP, Hotchkiss RN, Pederson WC,eds.
Green’s Operative Hand Surgery, 4th ed. New York: Churchill Livingstone, 1999, p 58.
This remarkable book is, in our opinion, the most valuable hand surgery text in print. Many of the
secondary procedures (which are nonmicrosurgical operations involving tendons, joints, and bone) are
referenced in chapters in this text, and the full discussion found there of each problem and operation
is well worth reading.
43. Freelander E. The relationship between cold intolerance and cutaneous blood ow in digital
replantation patients. J Hand Surg Br 11:15, 1986.
44. Backman C, Nystrom A, Bjerle P. Arterial spasticity and cold intolerance in relation to time af-
ter digital replantation. J Hand Surg Br 18:551, 1993.
45. Povlsen B, Nylander G, Nylanda E. Cold-induced vasospasm after digital replantation does
not improve with time: A 12-year prospective study. J Hand Surg Br 20:237, 1995.
46. Povlsen B, Nylander G, Nylanda E. Natural history of digital replantation:A 12-year prospec-
tive study. Microsurgery 16:138, 1995.
These authors describe in some detail the long-term outcome of replanted digits.
47. Hussl H, Jungwirth W, Hasenohrl K. Microsurgery for cold intolerance after nger replanta-
tion [letter]. Lancet 16:690, 1989.
48. Schwabegger AH, Hussl H, Rainer C, et al. Clinical experience and indications of the free ser-
ratus fascia ap: A report of 21 cases. Plast Reconstr Surg 102:1939, 1998.

1961
Chapter 47
Secondary Surgery Following Digit Replantation
1. Among the types of secondary operations, which of the following secondary
operations has the highest incidence?
a. Joint mobility and position
b. Tendon surgery
c. Soft tissue reconstruction
d. Nerve grafting
e. Amputation
2. A 34-year-old woman sustains a traumatic amputation of all digits. The digits
have been preserved and successfully replanted. Which of the following is the
most appropriate sequence in planning for secondary surgery?
a. Skin coverage, skeletal stabilization, nerve repair, joint reconstruction, ten-
don reconstruction
b. Skin coverage, joint reconstruction, skeletal stabilization, tendon recon-
struction, nerve repair
c. Skeletal stabilization, joint reconstruction, tendon repair, nerve repair, skin
coverage
d. Joint reconstruction, skeletal stabilization, nerve repair, tendon repair, skin
coverage
e. Nerve repair, tendon repair, joint reconstruction, skeletal stabilization, skin
coverage
3. A 42-year-old dock worker is brought to the emergency department after sus-
taining an amputation of the nondominant index finger just distal to the
metacarpophalangeal joint. On examination, the amputated part is macerated
and cannot be replanted. In this patient, ray amputation of the index nger may
result in which of the following?
a. Subsequent need for tendon transfer
b. Easier tting of a nger prosthesis
c. Restriction of the rst webspace
d. Loss of power grip and key pinch
e. Unacceptable cosmetic appearance
4. A 12-year-old girl has venous congestion of the thumb 8 hours after undergo-
ing a secondary operation after replantation.Which of the following is the most
appropriate next step in management?
a. Operative exploration of the veins
b. Operative exploration of the arteries
c. Application of leeches
d. Intravenous administration of heparin
e. Removal of the splint and dressings
R EVIEW QUESTIONS

1962
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
5. A 28-year-old man sustained a saw injury of his left little nger. Emergency
surgery consisted of full-thickness skin grafting, revascularization, exor tendon
repair, digital nerve repair, and replantation of the nger at the level of the mid-
proximal phalanx. A controlled trial of early motion is initiated after surgery.
Six weeks later, the patient suddenly loses the ability to ex the distal interpha-
langeal joint.Which of the following is the most appropriate next step in man-
agement?
a. Tenolysis
b. Arthrodesis
c. Continued physical/occupational therapy
d. Repeat operative exploration and repair
e. Corrective osteotomy

1963
It is intuitively obvious that the extent and depth of the original burn injury is in
large part responsible for the magnitude of persistent or residual hand deformity.
The correct management of the initial burn will go a long way toward minimizing
the need for secondary reconstructive surgery. Early excision and grafting of burn
wounds greatly improves the outcome.The deformities commonly seen in the past
can be signi cantly ameliorated or avoided entirely by proper splinting including
maintenance of interdigital web spaces, proper positioning of the metacarpopha-
langeal (MP) and interphalangeal (IP) joints, avoidance of vascular constriction or
compromise, and early motion with aggressive physical and occupational therapy.
Reoperative Surgery
After Excision and Grafting
of Upper Extremity Burns
William R. Dougherty, Joseph M. Mlakar, and R. Bruce Shack
C ha pter 4 8
Reoperative Problems
Unstable scars
Elbow contracture
Interdigital contracture
Axillary contracture
Wrist contracture
Suffering isn’t ennobling— recovery is.
Christiaan N. Barnard, MD

1964
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
Although the hands account for only 5% of the total body surface area, they are in-
volved in more than 70% of treated burn injuries.The hand is commonly burned
as an isolated injury and is rarely spared in burns covering more than 60% of the to-
tal body surface area. Burns of the hand may account for up to 8% of emergency
room visits for hand injuries and are often an indication for referral to a regional
burn center.
Typically, burns are an injury of the working class. Most hand burn injuries occur
in employed men. However, contact burns of the hand more frequently involve
small children.
Injuries that occur at the work site are more likely to be ame burns or electrical
burns. Injuries that occur at home are more likely to be the result of a scald, explo-
sion, or open ames.
Unlike the foot, which may still function as a cold, stiff, lifeless stump, the function
of the hand depends on stability, sensibility, mobility, dexterity, and controllable
power.This requires stable coverage and an adaptable skeletal framework and glid-
ing balance of multiple tendon/muscular forces. A person’s ability to function is
very dependent on the function of the hands. Our hands are organs of both func-
tion and beauty in our interactions with our environment and with others.
PRINCIPLES OF REHABILITATION
HAND THERAPY
ROLE OF THE HAND THERAPIST
No discussion of hand injuries or hand reconstruction is complete
without some mention of the hand therapist. Outcomes in hand sur-
gery can be very dependent on the participation and skill of these
trained professionals.
The hand therapist is a critical member of the plastic surgery team. Hand therapists
provide education to the patient, the patient’s family, and the medical staff.They are
the primary players in the management of edema, which reduces in ammation and
allows for early mobilization.They assist with range-of-motion exercises, with ac-
tive range always preferred over passive movement.They are responsible for main-
taining splinting and positioning of the patients.They support the patient through
the use of functional activity, developing strength in both ne pinch and power
grip. They provide tremendous psychosocial support for recovering patients and
their families, and they assist in pain management techniques.

CHALLENGES OF THE BURNED HAND
The most common challenges after an acute burn hand injury include thumb web
contractures, proximal interphalangeal (PIP) joint contractures of the digits, and
boutonnière deformities. Despite early splinting, adequate therapy, and vigilant
treatment, these deformities still occur because of the depth of the original burn
injury.
Common treatment obstacles during the rehabilitation phase include noncompliance
in the application of garments and splints by either the patients or the staff,delayed re-
habilitation progression, and delays in implementing range-of-motion exercises, cast-
ing,or dynamic splinting,or delayed referral to outpatient therapy after hospitalization.
POSTBURN RECONSTRUCTION
DEVELOPING A R ECONSTRUCTIVE PLAN
Half of the reconstructive demands for patients with severe burns involve the up-
per extremity, and half again of these involve the hand.The key to the plan is good
communication between the surgeon and the patient.
Surgeons need to help their patients to understand what is possible
and what is realistic. Surgeons must also listen to their patients to de-
termine exactly what they need and what they desire.
For some patients, the loss of self-image associated with the burn of the hand or
with other burns is so devastating that they may not want any additional defor-
mity.They opt for other types of treatment regardless of the advantages or expected
gains. For example, a young woman who has lost multiple fingers may opt for
metacarpal stacking as opposed to a toe-to-hand transfer simply because her feet are
still normal.
In formulating the plan for reconstruction of the burned hand, it is important to
take into account the rest of the extremity. In the upper extremity, function of the
elbow is critical to adequate positioning of the hand.
Given deformity at all three levels of the upper extremity, it is often
appropriate to do releases of the wrist, elbow, and axilla, completing
large motion reconstructions before attempting ner motion recon-
struction of the hand, although it is also possible to complete all of the
releases at a single setting.
1965
Chapter 48
Reoperative Surgery After Excision and Grafting of Upper Extremity Burns

1966
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
The most common contracture of the upper extremity is in the axilla.The most
common reconstruction need of the postburn hand is a web space release. The
timing and initiation of the burn reconstruction depends on the patient. Releases
can be performed during early active scar maturation. There is no need to wait
until the scars are fully matured.
COMMON SEQUELAE OF HAND BURNS
Postburn deformities are still common despite improvements in acute care. These
include the following:
First web space thumb adduction contractures
Other web space contractures
Dorsal skin contractures
Fifth- nger abduction deformities
MP joint extension deformities
Extensor tendon adhesions
Boutonnière deformities
PIP exion deformities
Median and ulnar nerve compression neuropathies
Amputation effect secondary to ischemic gangrene
Elbow and axillary contractures
Heterotopic ossi cation of the elbow or wrist
Obviously, most hand contractures do not occur in isolation but as combinations of
the preceding deformities. Also, hand problems commonly exist with deformities
of other body parts. Often, reconstruction of other areas takes precedence over re-
construction of the hand, especially if the patient is able to adapt to the deformity.
SURGICAL TREATMENT OF BURN SCAR CONTRACTURES
Principles for reconstruction of burn scar contractures include the following:
Incisional release of scars at each joint level to allow for maximum restoration
of movement
Excisional removal of hypertrophic scars when feasible
Restoration of transverse and longitudinal hand arches
Release or lengthening of deep tissue contractures including but not limited
to extensor tendons, lateral bands, and/or accessory collateral ligaments
Stabilization of bones and joints in positions of function with either internal
kirschner wires, external splints, or external skeletal xation
Resurfacing of the hand and digits with thin pliable acceptable tissues (skin
grafts if tendons are protected— aps if joints or tendons are exposed)
Use of local aps whenever feasible for reconstruction of web spaces

THE THICKER THE GRAFT, THE LESS SEVERE
THE CONTRACTURE
1967
Chapter 48
Reoperative Surgery After Excision and Grafting of Upper Extremity Burns
It has been debated for some time whether split-thickness grafts are better than
full-thickness grafts for the release of hand contractures.
The general thinking remains that thicker is better, especially for burns
in toddlers. However, a study by Pensler et al1 showed no differences
in treatment of contractures using split-thickness versus full-thickness
grafts.
The photos above show bilateral symmetrical dorsal hand burn wound contractures
treated by two different methods in the same patient.The photo on the left shows
a meshed thin split-thickness graft: Note the contracture lines and persistent red-
ness. In contrast, in the nonmeshed full-thickness skin graft shown on the right,
note the lack of contracture.
HYPOPIGMENTATION
Skin grafting can also be extremely useful for treatment of hypopigmentation of the
hand. Hypopigmented areas can be treated by dermabrasion and application of a
thin epithelial sheet graft.

1968
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
PEDICLE FLAPS FOR HAND R ESURFACING
A number of local flaps have been reported in the literature as being useful for
resurfacing the postburn hand. They include the cross- nger ap, reverse proper
digital artery ap, reverse dorsal digital ap, reverse rst- and second-metacarpal
aps, reverse forearm aps including ulnar, radial, and posterior interosseous pedi-
cled aps and distant aps such as the groin or epigastric aps.The rst photo (top
left) shows exposed tendon after burn scar contracture release; the second photo
(top right) shows a cross- nger ap inset over the PIP joint, and the gure on the
bottom shows a skin-grafted dorsal donor site.

A number of aps are available for thin free ap surfacing of the hand. Some of the
old workhorse aps for free tissue transfer, including the latissimus muscle ap, the
scapular ap, the parascapular ap, and the rectus abdominis ap, although useable,
typically are not suitable because of their thickness and bulk.Thin free tissue aps
such as the temporoparietal fascia and the serratus muscle are ideal to resurface the
dorsum. The top figure shows flap harvest, and the bottom figure demonstrates
donor site closure. Other commonly used aps are the free radial forearm ap, the
dorsalis pedis free ap, the lateral arm ap, and the arterialized venous free ap.
1969
Chapter 48
Reoperative Surgery After Excision and Grafting of Upper Extremity Burns
FREE FLAP SELECTION FOR HAND R ECONSTRUCTION

1970
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
SYNTHETIC MATERIALS
Integra, a dual-layer biosynthetic skin substitute consisting of a top silicone epi-
dermal sheet and a dermal layer composed of porous cross-linked bovine collagen
and chondroitin-6-sulfate, can be used in either the acute burn phase or for re-
construction. Integra provides a dermal substitute on which an epidermal graft can
be placed. Integra essentially fools the body into a “fetal wound-healing mode”
during which, instead of forming a scar, the collagen sponge induces the formation
of a “neodermis” without appendages. It takes approximately 3 to 4 weeks for tis-
sue ingrowth to create a neodermis.Then, after removal of the top silicone layer, a
thin split-thickness skin graft is placed. Use of Integra provides a dermal replace-
ment resulting in more elasticity and better aesthetic quality than a split-thickness
skin graft alone.
Several small studies have been published exploring the use of Integra in scar con-
tracture release. Hunt et al2 revised neck contractures in ve patients with an Inte-
gra base and found greatly improved function and cosmesis. Integra can be used
over viable tendons, bones, and even open joints to provide coverage. Integra may
provide a low-impact alternative to free tissue transfer in cases where skin grafting
could not be performed primarily. Remarkably, little tendon tethering has been
seen. The photograph above shows Integra placed over exposed tendon during
resurfacing of the dorsum of the hand.
A host of new bioengineered materials to replace dermis and composite skin is on
the verge of being approved for use as this book goes to press. Regeneration tech-
nology is in its infancy and promises to be an exciting avenue of research.

SURGICAL TREATMENT OF SPECIFIC
DEFORMITIES
HYPERTROPHIC SCARS
1971
Chapter 48
Reoperative Surgery After Excision and Grafting of Upper Extremity Burns
Hypertrophic scarring and scar contracture are the most common
problems seen in this group. Almost always, it is the dorsum of the
hand and the digits that are involved.
However, deep palmar burns may result in exion contractures requiring secondary
release and skin grafts.When the dorsum is involved with hypertrophic scarring or
scar contracture,full exion is impaired and the skin noticeably blanches with forced
exion. The web spaces may also be involved; most commonly the thumb/ index
nger web space with adduction contracture of the thumb. Less commonly, the lit-
tle nger is xed in an abduction contracture. In these cases the contracture is re-
leased, and the hypertrophic scar is excised down to the subcutaneous tissue and su-
per cial fascia leaving the dorsal veins intact whenever possible and resurfacing the
hand with a thick split-thickness skin graft that is applied as a sheet graft.
The peripheral margins of these excisions should be taken distal to
the joints and just beyond the longitudinal axis of the digit to mini-
mize recurrent scar contracture.
The photo on the left shows preoperative contracture caused by hypertropic scarring
and the photo on the right shows postoperative release.
A tourniquet should be used for the excision but should be released before graft ap-
plication to obtain meticulous hemostasis. If multiple joints are involved, they
should be held in the correct position before application of the skin graft with the
use of ne-gauge Kirschner wires.The MP joints should be exed to 110 degrees,
the PIP joints to 100 degrees, and the distal interphalangeal (DIP) joints to 145
degrees. These wires should be removed at the rst dressing change at about 3 to
5 days postoperatively to allow for early motion with physical therapy.

1972
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
CHRONIC POSTBURN JOINT PROBLEMS
In many patients the involvement of contractures is not limited to the skin and soft
tissues alone. The joints and associated supporting structures including ligaments
and capsules are also involved. At the time of scar release, MP and PIP capsulot-
omies can be helpful in improving motion, power, and dexterity to the hand if
combined with an appropriate postoperative hand therapy program.
Without appropriate postoperative therapy, capsulotomies will increase
the scarring and can result in worse postoperative function.
A program of capsulotomies should be discussed preoperatively with the desig-
nated therapist to ensure adequate follow-up and treatment.
If joints are severely damaged and painful, arthrodesis remains the procedure of
choice. Alloplastic arthroplasties are fraught with hazard in the light of severe over-
lying scarring and poor soft tissue mobility.Typically, attempted arthroplasty results
in chronic pain and eventual extrusion. Arthrodesis usually eradicates pain and pro-
vides stability to the joint to allow for function. Arthrodesis may be the best alter-
native in significant boutonnière deformities, especially in the absence of stable skin
coverage or if the joints are already dislocated.
METACARPOPHALANGEAL JOINT CONTRACTURES
These contractures almost always occur with the joints in extension. When the
skin is involved in the contracture, it must be excised with the distal skin margin ex-
tending past the joint and into all web spaces. If the skin is not too severely con-
tracted, vertical incisions can be made on either side of the joint or directly over the
joint dorsally for release of the joint capsule, collateral ligaments, and on occasion,
the extensor mechanism.Tenolysis of the extensor tendons and gentle mobilization
of the extensor hood off the MP joint is performed with both blunt and sharp dis-
section without destruction of any of the tendon bers, if possible. The approach
to the collateral ligaments is through a horizontal incision in the deep fascia and the
extensor retinaculum in the midlateral area directly over the joint spaces. After care-
ful excision of the collateral ligaments on both sides of the joint, a small curved
blunt dissector is inserted into the joint space, and with traction on the digit the dis-
sector is used to free the volar ligament from the metacarpal head. Flexion of the
MP joint should then be attempted passively and with minimal force. If adequate
exion through at least 60 degrees is not obtained, the dorsal capsule should be re-
leased from its bony insertion at the level of the MP joint. This will usually allow
for exion to near 90 degrees. A ne Kirschner wire is then inserted through the
metacarpal neck across the joint and down the entire length of the proximal pha-

lanx.These pins are removed at 10 days postoperatively. A dorsal splint is then used
at night to hold the MP joints in full exion, and active motion is allowed during
the day. Several weeks of splinting and therapy may be necessary before the patient
can actually extend the ngers to a full 180 degrees at the MP joint level. In some
patients a persistent but mild exion deformity develops that usually causes mini-
mal handicap.
PROXIMAL INTERPHALANGEAL JOINT EXTENSION
CONTRACTURES
If the contracture is rubbery and the skin is loose and abundant without adherence
to bone and the extensor tendons and lateral band mechanisms are still intact, it is
likely that the joint can be corrected by tendon and ligament release and tendon
lengthening. In most cases of burn-related contractures, this is not the case. In more
severe xed contractures with either destruction of the extensor tendon or its ad-
herence to bone, dorsal capsule, and collateral ligament, the choice may come down
to arthrodesis or arthroplasty. Arthroplasty is usually not possible if the extensor
mechanism is severely damaged and/or the skin coverage is inadequate. The nal
decision is usually made in the operating room after the joint has been surgically
exposed.The nger should be opened through radial and ulnar incisions on either
side of the joint rather than through a dorsal incision.The central slip of the exten-
sor mechanism requires careful dissection and elevation.The retinacular ligaments
are identi ed and incised on the radial and ulnar sides of the joint so that hood can
be mobilized toward the dorsal surface. The radial and ulnar lateral bands are
lengthened. If additional tissue is needed, the oblique bers can be detached prox-
imally and rotated distally to reinforce the retinaculum.This may allow an increase
of 30 to 40 degrees of exion. The central slip of the extensor tendon can be re-
leased from its periosteal attachment over the proximal phalanges, which can give
it an additional 20 degrees of exion at the PIP joint.The retinaculum is split ver-
tically, and the collateral ligaments are excised superiorly and inferiorly. The volar
plate is released opposite the articular cartilages but is not completely detached
from its insertion on to the phalanges. In some cases, it may be necessary to perform
a Z-plasty of the central slip to obtain a full 90 degrees of exion. If a Z-plasty is
done, the retinacular oblique bers are then used to reinforce the lengthened ex-
tensor tendon in the areas over the lateral bands. A ne Kirschner wire is inserted
through the proximal end of the middle phalanx and into the neck of the distal end
of the proximal phalanx attempting to avoid the articular surfaces.The hand is im-
mobilized with the MP joints toward extension and the PIP joints fully exed to
stretch out the lateral band mechanism.This position allows stretching of the intrin-
sic muscles and tendons, increasing grasp by allowing increased exion of the PIP
joints, increased extension of the MP joints, and improved range of motion in all ar-
eas of the hand.
1973
Chapter 48
Reoperative Surgery After Excision and Grafting of Upper Extremity Burns

1974
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
PIP JOINT FLEXION CONTRACTURES
PIP joint exion contractures,because of the volar scar,require scar excision,isolation
of the digital nerves and arteries, and release of the volar capsule, if necessary.This
is followed by xation with a Kirschner wire and application of a split-thickness
skin graft that can be held in place with a bolster dressing. The graft usually takes
quite well even when placed over digital nerves and exor tendon sheaths.
If the contracture is old and severe, it may be impossible to obtain full
correction at the first operation because of the danger of nerve stretch-
ing and spasm in the digital arteries. Maximum correction is attained
within the limits of safety, and a second procedure is planned at an ap-
propriate time in the future.
Furthermore, in children growth may cause recurrence of the contracture requir-
ing additional excision and grafting.The photo on the left shows PIP joint exion
contracture before a release split-thickness skin graft procedure and the photo on
the right is the postoperative result.
The advantage of volar contractures over dorsal contractures is that tendons typi-
cally do not come into play with release of volar contractures. Adequate paratenon
is present over the exor sheaths to allow for direct application of skin grafts. On
occasion, release is better performed with the application of small, localized aps to
prevent subsequent recurrence of the contractures. Finger volar contractures of-
tentimes can also be released using a series of Z-plasty aps, which also provide
better long-term stability than a skin graft.
During release of volar contractures, neurovascular bundles can easily be injured.
Neurovascular bundles can become displaced volarly getting encased in the scar.
Furthermore, release of the contracture can produce vascular ischemia of the dig-
its. Once the neurovascular structures become foreshortened in a long-standing
contracture, attempting overly aggressive release can produce irreversible spasms
within the vessel with loss of the nger.The tourniquet should be released and the
digits evaluated before completion of the volar contracture release. These digits
should be monitored carefully during the postoperative period.