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Hand/Peripheral Nerve: Case Report

Thumb Reconstruction after Severe Trauma Using the Masquelet Technique and the Foucher Neurovascular Flap

Luttenberger, Martin MD*; Taqatqeh, Feras MD; Dragu, Adrian MD; Bota, Olimpiu MD

Author Information
Plastic and Reconstructive Surgery - Global Open: September 2020 - Volume 8 - Issue 9 - p e3097
doi: 10.1097/GOX.0000000000003097

Abstract

INTRODUCTION

Masquelet technique is well known and well researched for treatment of extensive bone loss due to trauma, tumor, or infection.1 It includes a 2-stage procedure. In the first step, meticulous surgical debridement is followed by implanting a polymethylmethacrylate (PMMA) spacer to cover the void while preserving neurovascular structures and healthy soft and bone issue. Temporary fixation of the spacer is performed by either external or internal fixation.

After 4–8 weeks, the second-stage procedure is performed by removal of the cement spacer, repeated debridement while preserving the membrane, and insertion of autologous bone graft with appropriate bone fixation.2 It is widely used in limbs, but has been rarely described for reconstruction of the fingers, especially for the thumb.3–5

Foucher’s first dorsal metacarpal artery flap has been proved to be a reliable and safe method for soft tissue coverage of the thumb, with good clinical and aesthetic outcomes. It is a sensible (branches of the superficial radial nerve) flap that is being harvested from the dorsum of the proximal phalanx of the index finger to cover thumb defects. It is supplied by the first dorsal metcarpal artery and drained by two venae comitantes that are in connection with large cutaneous superficial veins in the first intermetacarpal space. The donor site is usually covered with full-thickness skin grafts from the thigh or groin6–8

CASE REPORT

A healthy 52-year-old man presented with acute trauma to the hand after reaching in a lawnmower. Clinical and radiological examinations showed a complex injury of the thumb with destruction of the distal two-thirds of the proximal phalanx and the interphalangeal-joint as well the loss of the dorsal soft tissues over the proximal phalanx and over the proximal third of the distal phalanx (Fig. 1A) (See figure, Supplemental Digital Content 1, which displays a radiological depiction of bone management. a. X-Ray after injury AP. b. x-ray immediately after K-Wire removal L. c. X-Ray eight months from injury L. d. X-Ray eight months from injury AP, http://links.lww.com/PRSGO/B464.) Minor soft tissue injuries on second and third finger including damage to fifth digital nerve were coexisting.

Fig. 1.
Fig. 1.:
Depiction of the soft tissue management. A, Soft tissues after injury. B, Induced bone membrane after spacer removal. C, Thumb after reconstruction. D, Final result achieved eight months after injury.

The treatment options were firstly evaluated, including amputation distal to the metacarpophalangeal joint, osteosynthesis of the remaining bone parts, or temporary wound closure and the secondary transfer of a free chimeric flap to reconstruct the destroyed parts. The treatment of choice implied in the first-stage surgery the radical debridement with resection of devascularized bone fragments, the replacement of the nearly completely destroyed proximal phalanx with PMMA bone cement containing Gentamycin and internal fixation via three 1.0 mm K-wires, as well as the reconstruction of the extensor tendon.

Postoperatively the patient’s thumb was immobilized in a cast. The patient was discharged 7 days after surgery with complete wound healing.

Six weeks after the initial operation, we replaced the PMMA spacer (Fig. 1B) with an autologous cancellous bone block graft (48 × 16 mm2) from the iliac spine and fixated the bone using two 1-mm K-wires. To augment the soft tissue, a Foucher flap was used to cover the dorsum of the thumb. The donor site was closed with a split-thickness skin graft (Fig. 1C). A short course of antibiotics was administered after each surgery. During the treatment, no local complications were encountered.

Physiotherapy was initiated after 1.5 weeks starting with active mobilization from the cast, followed by unencumbered stress when K-wires were extracted 8 weeks postoperatively.

After K-wire removal and starting with full mobilization, we noticed dorsal marginal bone resorption of 2–3 mm (Fig. 2B). Nevertheless, 8 months after surgery the bone fully consolidated (Fig. 2C, 2D), with excellent soft tissue conditions and function with ROM in the metacarpophalangeal-joint of 0–15–60 degrees and 8 points on the Kapandji opposition score (Fig. 1D). The iliac spine donor site healed inconspicuously and without any functional sequelae. At this time, the patient started the vocational reintegration.

DISCUSSION

In our case we present a novel technique, in which a severely injured thumb could be salvaged by combining the Masquelet technique and a Foucher flap.

Lum et al9 described the use of the Masquelet technique after a traumatic bone loss of the first metacarpal bone, but did not perform a consecutive flap transfer.

One case of induced membrane technique was reported to save an infected vascularized custom made toe-to-hand transfer.5 However this procedure was performed electively and not in an emergency setting.

Horta et al7 reported 56 cases of thumb reconstruction in an emergency setting using a Foucher flap with good results, but none of them were combined with the Masquelet technique.

One case of reconstruction with flap transfer as well as the Masquelet technique was reported by Herrison et al.3 In this case, however, a pedicled ulnar forearm flap was used to cover dorsal soft tissue defects of the fingers after bone reconstruction via the induced membrane technique. Three additional surgeries were needed to desyndactylize the fingers and de-fat the flap. Our study reconstructed the thumb with a different flap with less morbidity and requiring only 2 surgeries instead of 5. The prolonged treatment may impede early mobilization and compromise the functional results.

The radical debridement of injured and devascularized tissue was performed in the emergency setting, to minimize the risk of infection in a highly contaminated wound. Preserving the devascularized and contaminated bone could result in early infection, osteomyelitis, non-union, and loss of function. The resulting bone and dorsal soft tissue defect imposed for a safe, fast, and effective solution. As the soft tissue coverage of the PMMA-spacer was still possible by temporarily elongating the thumb by approximately 10 mm, we opted for a flap coverage at the secondary surgery. The Masquelet membrane is known to promote bone synthesis, without resorption. On the other hand, the Foucher-flap interruption of the Masquelet membrane with a fresh flap may result in bone resorption.1 This phenomenon could be seen in our case after K-wire removal in the vicinity of the Foucher flap. Nevertheless, this had no significant impact on the final result, as the bone completely consolidated after further mobilization. The option of a soft tissue coverage in the acute setting may also be taken into consideration, with respect to prolonged operation times and use of microsurgical techniques. Our case proved nonetheless that a secondary flap coverage, when feasible, is reliable and offers the advantage of a planned operative setting for the fine microsurgical flap preparation.

Alternatively, a free vascularized bone flap could be used to reconstruct the bone defect and the soft tissues either in the acute setting or secondarily after spacer implantation. The lateral femoral condyle free flap was used to reconstruct the thumb basal phalanx.10 The flap can be harvested with a skin island to replace the missing soft tissues. The shortcomings would be the need for special microsurgical expertise, the extended use of operative resources, and the donor site morbidity.

Our case shows that the use of the Masquelet technique and Foucher flap can be a useful tool for reconstructing bone and soft tissue while preserving the thumb’s full length after severe trauma with excellent functional and aesthetic outcomes. The same technique may be used in reconstructing the fingers using the first (Foucher) or second dorsal metacarpal artery flaps, depending on the injured finger.

ACKNOWLEDGEMENT

Open Access Funding paid by the Publication Fund of the TU Dresden.

REFERENCES

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2. Masquelet AC, Kishi T, Benko PEVery long-term results of post-traumatic bone defect reconstruction by the induced membrane technique. Orthop Traumatol Surg Res. 2019;105:159–166.
3. Herisson O, Masquelet AC, Doursounian L, et al.Finger reconstruction using induced membrane technique and ulnar pedicled forearm flap: a case report. Arch Orthop Trauma Surg. 2017;137:719–723.
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6. Delikonstantinou IP, Gravvanis AI, Dimitriou V, et al.Foucher first dorsal metacarpal artery flap versus littler heterodigital neurovascular flap in resurfacing thumb pulp loss defects. Ann Plast Surg. 2011;67:119–122.
7. Horta R, Barbosa R, Oliveira I, et al.Neurosensible reconstruction of the thumb in an emergency situation: review of 107 cases. Tech Hand Up Extrem Surg. 2009;13:85–89.
8. Muyldermans T, Hierner RFirst dorsal metacarpal artery flap for thumb reconstruction: a retrospective clinical study. Strategies Trauma Limb Reconstr. 2009;4:27–33.
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Supplemental Digital Content

Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.