(Alain C. Masquelet, Acacio C. Ferreira) Severe TR (BookFi) PDF

Severe Traumatic Defects of the Upper Limb
Severe Traumatic Defects of the

Upper Limb
Edited by
Alain C Masquelet
Professor of Orthopaedics and
Traumatology
Hopital Avicenne
Bobigny
France
Acacio C Ferreira
Director, Servico de Chirurgia
Plastica
Hospital Santa Maria
Lisbon
Portugal
LONDON AND NEW YORK

© 2003 Martin Dunitz, an imprint of Taylor & Francis Group
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CONTENTS
Contributors viii
INTRODUCTION
1 What is a severe defect?
Alain C Masquelet 1
SOFT TISSUE REPAIR: FLAP TECHNIQUES
2 Pedicled fasciocutaneous and adipofascial flaps

José Amarante 4
3 Pedicled muscle and musculocutaneous flaps

Christoph Heitmann and L Scott Levin 24
4 Free flaps
Horacio Costa 35
5 Emergency free flaps for the reconstruction of open injuries of the

upper limb 56
Maurizio Calcagni and Giorgio Pajardi
BONE RECONSTRUCTION
6 Bone auto-and allografts in post-traumatic reconstruction of the upper

limb 64
Olivier Barbier and Jean-Jacques Rombouts
7 Massive bone defects of the upper limb: reconstruction by
vascularized bone transfer 85
Michael B Wood
8 Loss of the post-traumatic infected substance of the upper limb
Ferdinando Da Rin, Mauro Ciotti and Alain Gilbert 100
9 Bone substitutes
Norbert Passuti, Lawrence Bigotte, Sophie Touchais, Joël Delécrin 120
and François Gouin
JOINT RECONSTRUCTION
10 Joint transfers and joint reconstruction

Luc Téot 132
11 Joint replacement as a secondary procedure
John K Stanley and Ian A Trail 142
12 Joint fusion in severe traumatic defects of the upper limb

Giorgio A Brunelli 152
NERVE DEFECT REPAIR
13 Nerve grafts
Michel Merle and Aymeric Lim 167
14 Bridging nerve defects: the role of tissue interpositioning

Göran Lundborg 189
15 End-to-side neurorrhaphy: an alternative method for reinnervation in

cases with long nerve defects 209
Manfred Frey and Pietro Giovanoli
TENDON DEFECT REPAIR
16 Conventional tendon grafting

Antonio Landi, Giuseppe Caserta, Norman Della Rosa and Andrea 224
Leti Acciaro
17 When to use vascularized tendon transfers and how is the digital
flexion sliding system supposed to work? 293
Jean C Guimberteau
COMPOUND TRANSFERS
18 Composite tissue transfer in the upper extremity

Günter Germann and Simone Brüner 312
19 Free functioning muscle transfer

Alain Gilbert and Vittore Costa 323
20 Combined soft tissue and tendon reconstruction: the dorsum and

thenar regions 334
Francisco del Piñal
GENERAL INDICATIONS
21 Principles of emergency reconstruction

Abel Nascimento 352
22 Principles or repair of a compound defect as a secondary procedure:
the multiple stages approach 365
Alain C Masquelet
23 Surgical management of infection
Manuel Llusa, Xavier Mir and Xavier Flores 377
24 Reconstruction of large defects of the upper limb in children

Massimo Ceruso, Filippo M Sènés, Giuseppe Checcucci, Prospero 388
Bigazzi, Alessandra Allegra and Gloria Taliani
25 Future advances in hand and upper limb surgery: application of tissue
engineering and biotechnology
Panayotis N Soucacos 400
Index 411
CONTRIBUTORS
Andrea Leti Acciaro
Unit of Hand Surgery and Microsurgery
Azienda Ospedaliera Policlinico of Modena
Italy
Alessandra Allegra
2a UO Anestesia e Rianimazione
Azienda Ospedaliera Careggi
Firenze
Italy
José Amarante
Plastic Surgery Department
São João University Hospital
Porto
Portugal
Olivier Barbier
Hand and Orthopaedic Surgeon
St-Luc University Hospital
1200 Brussels
Belgium
Prospero Bigazzi
UO Chirurgia della Mano e Microchirurgia
Ricostruttiva
Firenze
Italy
Laurence Bigotte
Clinique Chirurgicale Orthopédique
CHU Nantes
France
Giorgio A Brunelli
University of Brescia
Medical School
Brescia
Italy
Simone Brüner
Department of Hand, Plastic and
Reconstructive Surgery
Burn Center
BG Trauma Center and
Ludwig-Guttmann-Strasse 13
67071 Ludwigshafen
Germany
Maurizio Calcagni
Department of Hand Surgery
Policlinico MultiMedica
Institute of Plastic and Reconstructive Surgery
University of Milan
Via Milanese, 300
Sesto San Giovanni
Milan I-20099
Italy
Giuseppe Caserta
Italy
Massimo Ceruso
UO Chirurgia della Mano e Microchirurgia
Ricostruttiva
Firenze
Italy
Giuseppe Checcucci
UOC Chirurgia della Mano e Microchirurgia
Ricostruttiva
Firenze
Italy
Mauro Ciotti
Istituti Codivilla-Putti
Cortina
Italy
Horacio Costa
Plastic Surgery Department
Hospital Vila Nova de Gaia
Portugal
Vittore Costa
Institut de la Main
Clinique Jouvenet
6 square Jouvenet
F-75016 Paris
France
Joël Delécrin
CHU Nantes
France
Xavier Flores
Department of Trauma and Orthopaedic Surgery
Hospital de Traumatología Vall D’Hebron
Barcelona
Spain
Manfred Frey MD
Professor of Plastic Surgery
Head, Division of Plastic and Reconstructive
Surgery
Department of Surgery
Medical School
University of Vienna
Währinger Gürtel 18-20
A-1090
Austria
Günter Germann
Professor of Hand and Plastic Surgery
University of Heidelberg and
Professor of Surgery and
Chief, Department of Hand, Plastic and
Burn Center
BG Trauma Center and
Ludwig-Guttmann-Strasse 13
67071 Ludwigshafen
Germany
Alain Gilbert
Institut de la Main
Clinique Jouvenet
6 square Jouvenet
F-75016 Paris
France
Pietro Giovanoli
Professor of Plastic Surgery
Head, Division of Plastic and Reconstructive
Surgery
Department of Surgery
Medical School
University of Vienna
Währinger Gürtel 18-20
A-1090
Austria
François Gouin
Professor, Clinique Chirurgicale Orthopédique
CHU Nantes
France
Jean C Guimberteau
Chirurgie de la Main
Microchirurgie, Chirurgie Plastique,
Reconstructrice et Esthetique
54 rue Huguerie
Bordeaux 330000
France
Christoph Heitmann
Professor of Plastic and Orthopaedic Surgery
Division of Plastic, Reconstructive, Maxillofacial
and Oral Surgery
Duke University Medical Center, Box 3945
Durham, NC 27710
USA
Antonio Landi
Policlinico of Modena
Italy
L Scott Levin
Professor of Plastic and Orthopaedic Surgery
Division of Plastic, Reconstructive, Maxillofacial
and Oral Surgery
Duke University Medical Center, Box 3945
Durham, NC 27710
USA
Aymeric Lim
Consultant, Department of Hand and
Reconstructive Microsurgery
National University Hospital
Singapore
Manuel Llusa
Barcelona
Spain
Göran Lundborg
Malmö University Hospital
SE-205 02 Malmö
Sweden
Alain C Masquelet
Professor of Orthopaedics and Traumatology
Hopital Avicenne
125, route de Stalingrad
93009 Bobigny
France
Michel Merle
Head, Institut Européen de la Main
54320 Maxeville-Nancy
France
Xavier Mir
Barcelona
Spain
Abel Nascimento
Department of Orthopaedic Surgery
University Hospital
Coimbra
Portugal
Giorgio Pajardi
Policlinico MultiMedica
Institute of Plastic and Reconstructive Surgery
University of Milan
Milan
Italy
Norbert Passuti
Professor, Clinique Chirurgicale Orthopédique
CHU Nantes
France

Head, Section of Hand-Wrist and Plastic
Hospital Mutua Montañesa and
Director, Instituto de Chirugía de la Mano y
Plástica-Reparadora
Calderón de la Barca 16-entlo
E-39002 Santander
Spain
Ferdinando Da Rin
Istituti Codivilla-Putti
Cortina
Italy
Jean-Jacques Rombouts
Dean, School of Medicine
Université Catholique de Louvain and
Professor of Orthopaedic Surgery
St-Luc University Hospital
1200 Brussels
Belgium
Norman Della Rosa

Italy
Filippo M Sènés
1a UO Ortopedia e Traumatologia
Istituto Scientifico Giannina Gaslini
Genova
Italy
Panayotis N Soucacos
Professor and Chairman
Department of Orthopaedic Surgery
University of Ioannina
School of Medicine
45110 Ioannina
Greece
John Stanley
Centre for Hand and Upper Limb Surgery
Wrightington Hospital for Joint Diseases
Wigan
UK
Gloria Taliani
Clinica Malattie Infettive
Università degli Studi di Firenze
Italy
Luc Téot
Burns and Plastic Unit
Lapeyronie Hospital
Montpellier
France
Sophie Touchais
CHU Nantes
France
Ian A Trail
Centre for Hand and Upper Limb Surgery
Wrightington Hospital for Joint Diseases
Wigan
UK
Michael B Wood
Mayo Foundation
Rochester, MN
USA
Introduction
1
What is a severe defect?
Alain C Masquelet
When can a defect be considered as severe? This is not a mild question because the
answer is inevitably arbitrary.
I propose the following answer: a defect is severe when the restoration of the injured
structure cannot be performed without employing a palliative procedure. A limited bone
or joint defect can be neglected. For instance, a small defect of cartilage in a joint will not
have an effect on function. In case of soft tissue limited defect, direct restoration of the
continuity can be obtained owing to the suppleness of the involved tissue which can be
sutured. This is also the case for skin, arteries, nerves, muscles and tendons. In other
cases, direct suturing is not possible and the defect cannot be neglected without an
inacceptable functional impairment.
The aim of this textbook is to provide some answers to the following questions:
• How to repair a severe defect of a tissue of the upper limb?
• What are the surgical procedures and what are their respective indications according
to the features of the defect?
• How to reconstruct a long bone defect?
• How to perform a joint fusion when there is a bone defect?
• What are the possible methods to restore the skin envelope, the continuity of nerves
and tendons, etc.?
All the answers to these questions require a good knowledge of conventional procedures,
state-of-the-art advances in bioengineering and imagination. The course includes surgical
precedures and general indications.
The upper limb is an assembly of structures and tissues devoted to supporting the
prehensile function of the hand.
The initial trauma may lead to a variety of associated lesions of several tissues. A
limited defect of the skin envelope can be combined with a severe defect of a long bone.
In this situation we only consider the severe defect of the bone. But if a severe defect
involves two or more structures, we call it a compound defect.
A compound defect is the combination of several severe defects with varying degrees
of involvement of the skin, muscles, bone, joints, tendons, nerves, arteries, etc. Thus we
can give some definitions.
• A defect always implies a defect of a particular tissue which is a component of the
musculoskeletal system.
• A severe defect cannot be treated without a palliative procedure of replacement.
• A compound defect is the combination of several severe defects.
Another important question is: How to repair a compound defect?
Severe traumatic defects of the upper limb 2
In this book two possibilities are considered: the replacement of each isolated tissue or
the use of a compound transfer which allows the repair in a one-stage procedure. The aim
is to provide an holistic view of all possibilities including the latest advances in
bioengineering. The replantation of amputated segments of the upper limb and the severe
injuries of the fingers will not be discussed.
Soft tissue repair: flap
techniques
2
Pedicled fasciocutaneous and adipofascial
flaps
José Amarante
Introduction
The forearm island flaps are probably, at present, one of the surgical techniques utilized
most fre
Figure 1
(a) A dorsal hand lesion. (b) The final result after a distally
pedicled radial forearm flap.
Pedicled fasciocutaneous and adipofascial flaps 5
quently for reconstructive surgery of the hand. These flaps are based on the arteries and
veins of the forearm and their septocutaneous branches. Their main advantages include
the use of fasciocutaneous or adipofascial areas of reasonable dimensions, ease of
reinnervation and their possible use as composite flaps. The last option allows the
execution of cutaneous, tendinous and osseous reconstructions in the same operating
time.
The forearm radial flap (Fig. 1) was first described in plastic surgery literature as a
free flap (Yang et al 1981) and later as a distally pedicled flap for hand reconstruction. It
was used in cutaneous reconstructions (Stock et al 1981), reinnervation of the
reconstructed area (Schoofs et al 1983) as well as in tendocutaneous (Reid and Moss
1983) and osteocutaneous reconstructions (Biemer and Stock 1983, Schoofs et al 1983).
This flap can also be utilized as an adipofascial flap (Fig. 2) or as a purely fascial flap
(Reyes and Burkhalter 1988). Presently it is one of the flaps that is used more frequently
in reconstruction of the hand or as a free flap in diverse anatomical areas such as the oral
cavity (Boyd et al 1994), the leg (Muhlbauer et al 1982) and the penis (Gottieb and
Levine 1993). Some technical modifications have been recently published: an
adipofascial flap pedicled in a single distal perforator artery preserving the radial artery
(Weinzweig et al 1994, Koshima et al 1995) and also a radial forearm flap without the
fascia for lowering the morbidity of the donor area (Lutz et al 1999).
The ulnar forearm flap (Fig. 3) was initially described as a free flap (Lovie et al 1984)
but is also used with a distal pedicle in reconstructive surgery of the hand (Elliot et al
1988, Glasson et al 1988, Guimberteau et al 1988). As a free flap
Figure 2
(a) Planning an adipofascial radial forearm flap. (b) The
dissection of the adipofascial radial forearm flap. (c) The
adipofascial flap. (d) An aspect of the final result.
and in a way similar to the radial forearm flap, it has surgical applications in various
areas, namely the face, penis and leg (Christie et al 1994). It can be used as a cutaneous
flap but also as a composite flap with tendons or bone from the ulna (Christie et al 1994).
It is centred in the forearm in a position symmetrical to the radial flap and, as its name
implies, is supplied by the ulnar artery and its septal branches. A large area of skin and
subcutaneous cellular tissue of the anterior region of the forearm can be used in this type
of flap.
The radial and the ulnar forearm flaps, when utilized with a distal pedicle, are
vascularized inversely to the normal flow secured by various existing anastomoses
between the radial and ulnar arteries.
Another flap that has identical vascularization when pedicled distally is the posterior
interosseous flap (Fig. 4) (Zancolli and Agrigiani 1986). In this case, the circulation is
assured by the existing anastomosis between the two interosseous arteries localized
normally in the distal third of the forearm (Penteado et al 1986). This flap is almost
exclusively used in reconstructive hand surgery (Masquelet and Penteado 1987, Maillard
and Meredith 1991, Angrigiani et al 1993) as an osteocutaneous flap (Costa et al 1988)
although some clinical cases have been described with reconstructions in other areas
using this flap as a proximally pedicled flap (Nakajima et al 1986) or as a free flap
(Tonkin and Stern 1989).
Figure 3
(a) A lesion located on the dorsum of the hand. (b)
Planning an ulnar forearm flap. (c) The dissection of the
flap. (d) The final result.
Figure 4
(a) Planning a posterior interosseous flap to reconstruct a
dorsal hand lesion. (b) The final result.
Figure 5
(a) A dorsal lesion on the hand. (b) The final result after an
ulnodorsal septocutaneous flap reconstruction.
Contrary to the flaps already described, the ulnodorsal septocutaneous flap (distal ulnar
artery island flap) (Becker and Gilbert 1988a, 1991) and the median flaps (Niranjan and
Shibu 1994) are supplied with a blood flow in the normal direction: the former through a
distal branch from the ulnar artery (Fig. 5) (Becker and Gilbert 1991, Holevich-
Madjarova et al 1991, Niranjan and Shibu 1994) and the latter through a branch from the
median artery. The median flap is rarely used in clinical practice as the median artery is
rarely identified.
For reconstructions in the elbow area it is possible to use flaps based on the recurrent
radial or ulnar arteries with reverse flow (Figs 6 and 7).
The recurrent radial artery has been used in a musculocutaneous flap based on the
brachioradial muscle (Lai et al 1981) while the collateral radial artery is the base of a free
flap (Song et al 1982, Katsaros et al 1984). The use of these two arteries for the execution
of the inverted flow flap was first described by Maruyama (Maruyama and Takeuchi
1986) and later more clinical cases were described (Culberston and Mutimer 1987).
Several authors described the execution of free flaps in the medial arm area (Daniel et
al 1975, Dolmann et al 1979); the execution of the island flap with a proximal pedicle has
also been described (Budo et al 1984). Maruyama was the
Figure 6
(a) The area demanding reconstruction. (b) The final result
with the recurrent ulnar flap.
first to describe an inverted flow flap based on the recurrent ulnar artery and the collateral
superior ulnar artery united by their anastomoses (Maruyama et al 1987). Kadry has also
presented some clinical cases using this flap (Kadry et al 1989).
All the flaps described can be used as fasciocutaneous or adipofascial flaps. For
adipofascial flaps and before starting the true dissection of the flap, it is necessary to lift
the skin from both margins of a longitudinal incision located in the long axis of the flap.
It is obvious that the flap must include the main artery supplying the flap and the local
fascia.
Other flaps like the anterior interosseous (Hu et al 1994) and the neurocutaneous
(Bertelli 1993, Bertelli and Pagliei 1998) are not large enough to reconstruct large defects
so they are not discussed in this chapter.
Figure 7
(a) A recurrent radial flap for reconstruction of the anterior
surface of the elbow. (b) A recurrent ulnar flap already
dissected. (c) The final result. (d) The donor areas.
Still another option for hand reconstruction is to execute venous flaps in the forearm
which, as the name indicates, avoids the use of arteries for the cutaneous blood supply
(Amarante et al 1987, Thatte and Thatte 1987, Amarante et al 1988).
Radial forearm flap
The radial flap (see Fig. 1), which can be dissected from a vast area of the anterior region
of the forearm, is based on the radial artery and its septal branches as they pass at the
proximal level between the brachioradialis and flexor carpi radialis muscles and at the
distal level between the flexor carpi radialis and the flexor digitorum superficialis
muscles.
If necessary, it is possible to use a musculocutaneous composite flap once the radial
artery supplies the flexor carpi radialis, brachioradialis and palmaris longus muscles.
Analogically, fragments of the radius could also be used given the fact that they are
vascularized by the radial artery either directly or indirectly through the periosteal
branches of the insertions of the flexor pollicis longus and pronator quadratus.
The flap could be resensitized utilizing either the lateral or the medial cutaneous
nerves of the forearm.
The venous drainage of the flap is effected through the superficial venous system
which communicates with the deep veins, satellites of the radial artery, the blood flowing
posteriorly contrary to the normal flow.
Surgical technique
Before surgery, the permeability of the arteries of the hand must be evaluated by Allen’s
test.
The flap must be designed on the forearm centred on the trajectory of the radial artery.
Next, an incision is made on the ulnar edge of the flap which must include the skin,
subcutaneous tissue and fascia (easily identifiable at this level).
The flap is raised from its bed with the exposure of the forearm muscles, which is
achieved by sectioning the intermuscular septa that run from the deep surface of the
fascia to the subjacent muscles. Maintaining this plane of dissection assures the
connection of the radial artery to the flap once this is localized in the lateral intermuscular
septa. The sectioning of the periosteal insertion of the lateral septum allows the liberation
of the radial artery and the two satellite veins. With these vessels already referred to, the
incision can proceed to the radial margin of the flap followed by its dissection in the
subfascial plane.
The retraction of the brachioradialis muscle permits the exposure of the superficial
branch of the radial nerve which must be kept intact.
After ligation of the proximal end of the radial artery and the two satellite veins, the
flap can be lifted out progressively dissecting the pedicle towards the distal end.
In the event that the intention is the reinnervation of the flap, one can proceed with the
identification and isolation of a nerve in the cutaneous area of the flap.
Normally the arc of rotation of the flap reaches the hand, that is the fingers, though
one can substantially increase that arc of rotation by dissecting out the pedicle of the flap
at the level of the anatomical snuff box in a manner that facilitates the passage between
the abductor pollicis longus and extensor pollicis brevis muscles.
If the intention is to include a bone fragment with the flap, the insertion of the lateral
intermuscular septum in the periosteum of the radius must be preserved intact. In this
case, the dissec tion of the flap must be done more deeply through the flexor pollicis
longus and the pronator quadratus muscles until the radius is reached.
The donor area of the flap is usually closed with a dermo-epidermic graft, care being
taken to first cover the tendons of the flexor carpi ulnaris and brachioradialis muscles and
the superficial branch of the radial nerve. This is achieved by suturing the flexor
digitorum superficialis to the flexor pollicis longus muscle.
Ulnar forearm flap
The ulnar forearm flap (see Fig. 3) is based upon the ulnar artery and its septal branches
which reach the fascia by passing between the flexor carpi ulnaris and flexor digitorum
superficialis muscles.
The venous drainage of the island pedicle flap occurs through the satellite veins of the
ulnar artery.
This flap can be resensitized using the medial cutaneous nerve of the forearm. The flap
can also include muscles (flexor carpi ulnaris and palmaris longus) as well as a bone
fragment from the ulna.
Surgical technique
Before raising the flap and because an important artery supplying the hand is going to be
ligated, Allen’s test must be done to confirm the permeability of the radial artery.
Once the permeability of the arterial vessels is verified, the flap is designed on the
forearm, beginning the intervention by the identification of the ulnar artery at the distal
end. The lateral edge of the flap is then incised up to the fascia, the flap being separated
previously from the flexor digitorum superficialis muscle. If necessary the palmaris
longus muscle or part of the flexor carpi ulnaris muscle could be included. The flap
separation is continued at this level until the fascial septum separating the flexor
digitorum superficialis muscle and flexor carpi ulnaris muscle is exposed. In this phase of
the intervention, the septal branches of the ulnar artery are quite visible. The incision is
concluded along the periphery of the flap, ligating, if necessary, some superficial veins
and identifying the medial cutaneous nerve of the forearm in case the intention is to
resensitize the flap.
After the separation from its bed, the flap must now be progressively separated from
the ulnar nerve. Next proceed with the sectioning of the ulnar artery and its satellite veins
immediately after it gives rise to the common trunk of the interosseous arteries in such a
way as to permit the transposition of the flap. Usually it is necessary to dissociate the
vascular pedicle of the flap from the ulnar nerve at the distal end level and to ligate some
arterial muscular branches.
The donor area of the flap can be closed directly if it is of reduced dimensions
otherwise it is necessary to use a dermo-epidermic graft.
The posterior interosseous forearm flap
The posterior interosseous flap (see Fig. 4) is based on the artery of the same name and
its septal branches. The flap is located on the posterior region of the forearm where the
artery emerges at this level in the deep face of the supinator muscle. The point of
emergence is approximately at the union of the superior third with the median third of a
line that unites the epicondylus lateralis to the processus styloideus of the ulna. At the
level of emergence of the artery on the posterior face of the forearm, it is accompanied by
the posterior interosseous nerve. The nerve gives rise to a small branch that accompanies
the artery in its distal trajectory. These two structures accompanied by the two satellite
veins of the artery pass into the fascial septum situated between the extensor carpi ulnaris
and extensor digiti minimi muscles.
Surgical technique
The surgery begins by drawing a line that unites the epicondylus lateralis to the processus
styloideus of the ulna, corresponding to the trajectory of the posterior interosseous artery.
The line must be drawn with the forearm in complete pronation and with the elbow
flexed.
The flap must be designed on the posterior region of the forearm so as to include the
emergence of the posterior interosseous artery. Before the flap is raised at the distal level,
the anastomosis between the two interosseous arteries must be confirmed. Then the
incision into the skin and afterwards into the fascia can be done in such way as to
preserve the anastomosis. After the verification, the incision of the flap proceeds at its
periphery separating it from the muscular bed on both sides of the intermuscular septum
until the emergence of the interosseous artery can be seen. In this phase it is crucial not to
damage the posterior interosseous nerve.
After the artery is ligated proximally the flap can be completely separated from the
muscular bed and after the distal dissection of the arteriovenous pedicle, it can be
transposed to the hand.
If the flap is of small dimensions, one can close the donor area of the flap directly,
otherwise it is necessary to apply a skin graft.
Ulnodorsal septocutaneous flap (distal ulnar artery island flap)
This flap uses the distal branches of the ulnar artery in the forearm (see Fig. 5), which run
directly to the forearm fascia passing the posterior surface of the flexor carpi ulnaris
muscle. After ramifying and anastomosing at the level of the fascia with other branches
of the septal arteries these distal ulnar branches are going to supply a localized area at the
ulnar edge of the forearm extending between the trajectory of the palmaris longus and the
extensor indicis muscles.
Surgical technique
The flap is drawn on the ulnar edge of the forearm and is centred largely on the anterior
region. It axis of rotation is located in the plane of emergence of the most distal
septocutaneous artery, which is situated about 3–4 cm from the pisiform bone. Eventually
a second perforating artery about 7–8 cm from the pisiform bone can also be included.
Usually, one proceeds with raising the flap from proximal to distal, incising the skin,
the subcutaneous tissue and the fascia. This structure, in the area of the flexor carpi
radialis muscle is thinner and difficult to dissociate from the muscle. It the flap is raised
by proceeding distally one is able to see the first perfusing artery located about 7 cm from
the pisiform bone, which can also be included in the flap. During the dissection at the
distal level, damage to the dorsal branch of the ulnar nerve must be avoided.
Then the flap is completely separated from its bed, remaining attached only by its
artery and vein, which permits easy transposition to the dorsal or the palmar regions of
the hand.
The donor area of the flap, if it is of reduced size, can be closed directly. In the case of
large flaps, a skin graft easily closes the donor area.
Recurrent radial flap (lateral arm flap with inverted flux)
This flap is located on the external margin of the arm and is based on the recurrent radial
artery which is usually a branch of the radial artery. This artery, after giving rise to some
muscular arterial branches to the supinator and brachial muscles leads proximally
anastomosing with the collateral radial artery.
Surgical technique
The shape of the flap is drawn on the outside of the arm centred on a line that unites the
lateral epicondyle to the inferior edge of the deltoid muscle.
The incision, normally initiated at the anterior edge of the flap, must include skin,
subcutaneous tissue and brachial fascia up to the muscular plane.
The flap is then progressively raised from its bed, allowing the identification of the
recurrent radial artery that is dissected in a manner to maintain its link with the flap
through the septal prolongation of the fascia.
The incision is afterwards completed on the whole periphery of the flap, which is
completely raised from its bed, remaining attached at the distal end by the recurrent radial
artery and its satellite veins after they are proximally ligated.
Depending on the width necessary for the flap, the closure of the donor area may or
may not require a skin graft.
Recurrent ulnar flap (medial arm flap with inverted flow)
This flap is found, as the name indicates, on the internal face of the arm (see Fig. 6) and
is centred on the vascular axis constituted by the recurrent ulnar artery and the collateral
ulnar arteries joined by their respective anastomoses.
The recurrent ulnar artery divides after its origin into two arterial branches, one
anterior and the other posterior, the latter having the greater calibre and an ascending
trajectory between the bundles of the flexor carpi radialis. This branch artery with the
greater dimension passes in its proximal trajectory along with the ulnar nerve behind the
humeral epicondyle in order to anastomose with the superior collateral ulnar artery.
Surgical technique
After drawing the flap on the medial face of the arm, between the anterior and posterior
medial lines, the incision is made into the skin, subcutaneous tissue and the brachial
fascia in the anterior margin of the flap. Afterwards the flap is raised from its bed
exposing the fascial septum between the triceps brachii and brachial muscle, which is
incised longitudinally, care being taken not to injure the ulnar nerve. During this phase of
the dissection, the recurrent blood vessels are normally identifiable.
Clinical cases
A total number of 246 forearm island flaps were performed, of which 117 were radial
forearm flaps, 6 were ulnar forearm flaps, 43 were posterior interosseous flaps and 80
were ulnodorsal septocutaneous flaps. Two radial forearm flaps were performed in direct
flow.
There were 157 male and 99 female patients, ranging in age from 1 year to 74 years.
All the flaps were done by bloodless technique with the patients under endovenous
anaesthesia, brachial plexus block or general anaesthesia.
Of the cases, 111 were treated as a result of burns, 135 as result of emergency hand
trauma and 11 were reconstructions following neoformation treatment. The dorsal region
of the hand was the area treated most frequently (Table 1).
The complications are shown in Table 2. We had difficulty in closing the donor area in
some cases as a result of the skin graft revascularization, which had the inconvenience of
prolonging the recovery period.
Oedema was found in some flaps, a complication which was easily resolved in the
majority of cases using an elastic bandage. Only in the case of one radial forearm flap did
the oedema persist beyond 3 months. The difficulty of extension of the fifth finger was
observed in four cases, in which the posterior interosseous flap was used.
Table 1 Reconstructed areas and flaps used.

Radial Ulnar Post Ulnodor Radial recur Ulnar recur
inter
Hand dorsum 44 3 28 36
Hand palmar 21 3 4 12
Hand ulnar 8 20
border
1st web space 19 3 12
Fingers 10
Hand + fingers 21
Elbow 2 3 10
TOTAL 117 6 43 80 3 10
Radial, radial forearm flap; Ulnar, ulnar forearm flap; Post inter, posterior
interosseous flap, Ulnodor, ulnodorsal septocutaneous flap, Radial recur,
recurrent radial flap, ulnar recur, recurrent ulnar flap.
Table 2 Complications of the different flaps used.

Partial Oedema Nervous Muscle
necrosis complications complications
Radial forearm 4 33 11
Ulnar forearm 2 5
Ulnodorsal 3 8 1
Posterior 3 9 2 4
interosseous
Radial recurrent 1
Ulnar recurrent 1
TOTAL 12 52 19 4
Transient paraesthesia was noted in three patients in the area reinnervated by the ulnar
nerve at the level of the hand, which disappeared completely about 3 weeks after surgery.
Thirteen patients had dysaesthesia.
Considering the recurrent radial and ulnar flaps, ten recurrent ulnar and three recurrent
radial flaps were performed in nine men and four women, between 22 and 36 years old.
We preferred the recurrent ulnar flap since its donor area is easier to conceal. All the
donor areas, except four cases, were directly sutured. In those four cases we used skin
grafts to close the donor area. Both these flaps were used to reconstruct the anterior
region of the elbow and in two cases we had to use both flaps (see Fig. 7) to accomplish
the goal as the areas that demanded reconstruction were of large dimensions.
Total necrosis was not observed in any of the flaps. Partial necrosis on the periphery
of two of the flaps was observed.
Discussion
The flaps described are safe and in general easy to execute and can be used as
fasciocutaneous or adipofascial flaps.
We must consider several issues in the choice of antebrachial flaps: the anatomical
variations; the point of rotation of the pedicle; the vascular disadvantages; and the scar in
the donor area.
Anatomical variations of the radial and ulnar arteries are rarely impediments to the
raising of this flap (McCormack et al 1953, Coleman and Anson 1961, Amarante 1990).
For example, the presence of the superficial ulnar artery, which occurs in 2–3% of the
cases (McCormack et al 1953, O’Rahilly 1986), was initially considered to be an obstacle
for the use of this flap (Fatah et al 1985), although clinical practice shows that its
presence facilitates the raising of this flap (Glasson and Lovie 1988, Reis et al 1994).
In every case and prior to the dissection, the viability of the hand circulation after the
occlusion of either the radial or ulnar arteries must be verified by Allen’s test or by
Doppler fluxometer (Gelberman and Blasingame 1981, Emerson et al 1985).
Nevertheless, a negative Allen’s test is not an impediment to the execution of this flap
(McGregor 1987a). So if one persists in raising the flap, during the operation the artery to
be ligated must be clamped prior to raising the flap, which will permit the evaluation of
the circulation of the hand (McGregor 1987b). This precaution is particularly important
in traumatic injuries since the circulation can be interrupted in one of the main axes of the
arm or in the vascular arcs of the hand. However this situation is rarely verified given that
the anastomoses between the radial and ulnar arteries at the distal end are through the
palmar and dorsal arcs, which usually permit raising the flap even in the presence of local
lesions at the carpal level.
The posterior interosseous flap, like the radial and ulnar flaps, is irrigated in inverted
flow through the anastomoses between the interosseous arteries, which requires
confirmation of its presence prior to the complete raising of the flap.
In our work with 50 forearm dissections we verified that the anastomotic system was
absent in one case and bilaterally absent in another case (Amarante 1990) although some
authors reported after 100 upper arm dissections that only in 50% of the cases is there a
real interosseous system (Huelin et al 1978, Barreiro and Huelin 1980).
Penteado reported the absence of the same anastomosis in one of 70 cases studied
(Penteado et al 1986) contrary to another study in 50 cases in which the anastomosis was
always encountered between the two interosseous arteries (Costa et al 1991).
The absence of the artery in the middle of the forearm, which also makes the
execution of the flap unfeasible, was verified in four, two and one of 80, 36 and 70 arms,
respectively (O’Rahilly 1986, Maillard and Meredith 1991, Angrigiani et al 1993). The
absence of the same artery at the distal end in one clinical case was reported (Angrigiani
et al 1993) and we have also observed in a clinical case bilateral disappearance of the
artery in the middle third of both forearms preventing the use of the posterior
interosseous flap. The patient was a 46-year-old man with a severe bilateral Dupuytren
contracture with involvement of the skin (Costa et al 1991). Considering all the
anatomical data presented, prior to the execution of the posterior interosseous flap and
consequently the proximal sectioning of the artery, it is necessary to confirm its presence
at the distal level and the anastomosis with the anterior interosseous artery.
Relative to the distal septal branch of the ulnar artery, its absence was report in one
(Becker and Gilbert 1991) and in three (Amarante 1990) of 50 cases studied, so it is
advisable to confirm its presence prior to raising the flap.
During the execution of the ulnodorsal septocutaneous flap (Becker and Gilbert
1988a,b), we always try to include, whenever it is possible, a second septal artery which
is normally located about 7 cm from the pisiform bone—which was regularly
encountered in 50 dissections (Amarante 1990) and the superficial forearm fascia because
we think this forearm flap is identical to the posterior septocutaneous tibial flap in the leg
(Amarante et al 1986), both having a vast vascular network at the fascial level between
the septocutaneous arteries, making it possible to raise a flap of appreciable dimensions
based on one or two perforating arteries. Other flaps like these can be dissected in the
arm using the fasciocutaneous arteries located by Doppler flowmeter (Bertelli 1993,
Bertelli and Pagliei 1998).
The chances of execution of the median flap are very uncertain owing to its
anatomical characteristics. The median artery is reported to be constantly present (Huelin
et al 1978) but the fact is that it has a reasonable calibre in only 8% of cases (Niranjan
and Shibu 1994). Even in these one must confirm the presence of the perforating
cutaneous artery which is absent in the great majority of cases.
In the utilization of inverted flux flaps, the position of the rotation point of the pedicle
can influence the selection, consonant with the area to be reconstructed. That point is
related to the existing anastomosis between the two arteries which supply the flap. In the
case of the ulnodorsal septocutaneous flap, its point of rotation is located at the level of
origin of the most distal septocutaneous artery from the ulnar artery. The anatomical
characteristics of the radial and ulnar forearm flaps permit reconstructions including the
fingers and areas of the hand distal to the metacarpophalangeal joints where using either a
posterior interosseous flap or an ulnodorsal septocutaneous ulnar flap was not indicated.
An important factor in the choice of the flap is the vascular inconvenience resulting
from the arterial ligation, as it will have repercussions in the forearm and hand blood
supply. The ulnodorsal septocutaneous flap and other flaps based on the fasciocutaneous
or neurocutaneous arteries (Bertelli 1993, Bertelli and Pagliei 1998) are, in this aspect,
the ones with fewer vascular repercussions if the arterial branches utilized are almost
exclusively cutaneous. The large calibre ulnar and radial flap arteries will be ligated at
the proximal end in the forearm when the flap is completed. The interruption of any of
these large arteries at the forearm level has negative repercussions, most of all, on the
muscular and nervous vascularization. At the muscular level in the forearm, the ulnar
artery practically supplies the flexor digitorum superficialis (Parry et al 1988, Parry and
Mathes 1989, Revol et al 1991). The radial artery has only one muscular branch of
significance to the pedicle of the flexor carpi radialis muscle (Parry et al 1988, Parry and
Mathes 1989, Revol et al 1991). This muscular branch is found quite proximally and is
not usually sectioned in the execution of the radial forearm flap. In contrast to the arteries
already referred to, the interosseous arteries are of great importance at the forearm level,
namely the posterior interosseous artery which supplies practically all the muscles of the
posterior compartment of the forearm (Parry et al 1988, Parry and Mathes 1989, Revol et
al 1991): extensor digitorum communis, extensor carpi ulnaris, extensor digiti minimi,
abductor pollicis longus, extensor pollicis brevis, extensor pollicis longus, supinator and
extensor indicis. This fact could explain the difficulty in effecting the extension of the
fifth finger—verified in four patients on whom we executed this flap—the extensor digiti
minimi is practically exclusively supplied by the posterior interosseous artery.
Of great importance and also deserving mention is the contribution of the arteries of
these flaps to the blood supply of the main nerves of the forearm. The ulnar nerve is
mostly supplied by the ulnar artery while the superficial branch of the radial nerve, a
sensory nerve, is supplied by the radial artery while its motor branch is supplied by the
posterior interosseous artery (Bellinger and Smith 1980, Pinal and Taylor 1990). The
paraesthesias reported by some authors (Christie et al 1994, Amarante 1990), resulting
from the execution of the ulnar flap, are probably, to a greater extent, related to the minor
trauma verified during the dissection of the flap than a diminution of the vascular flow, as
recuperation from this complication is usually fast.
Relative to the repercussions of the diminution of the blood supply at the level of the
hand owing to the utilization of these flaps, it must be said that the perfusion by the distal
septocutaneous ulnar artery as well as by the posterior interosseous artery contributes
minimally to the vascularization of the hand through their anastomoses with the palmar
and dorsal arcs.
The major importance of the ulnar artery relative to the radial artery in the hand
circulation is noted in the references (Barreiro and Huelin 1980). Therefore, it must be
emphasized that the radial artery contributes significantly to the blood supply of the
thumb and index finger (Coleman and Anson 1961, Mutz 1972, Braun 1977, Parks et al
1978). The importance of these arteries in the circulation of the hand was the main reason
to perform venous bridges (Soutar et al 1983, Lovie et al 1984) but later it was reported
that those venous bridges soon became occluded (Gelberman et al 1982, Boorman and
Sykes 1987, Meland et al 1993). Recently, a study was published which compared the
vascular status of one hand where a free radial forearm flap had been harvested without
radial artery reconstruction, with the vascular status of the contralateral normal hand and
the authors concluded that the vascular repercussions were not significant (Meland et al
1993).
When using flaps based on the radial, ulnar and interosseous arteries we must consider
the sequelae not only in the hand but also in the forearm.
Another factor to consider when selecting the type of flap to use is related to the donor
area. Whenever the execution of large flaps requires skin grafts, they take better in ulnar
and interosseous flap donor areas once the graft is applied over the muscle mass with
good vascularization (Glasson and Lovie 1988). When raising a large or a distally
localized radial forearm flap there will be tendons exposed with deficient blood supply
making revascularization of the graft difficult and prolonging the recovery period. This
problem is more frequently encountered when using large free flaps. Several techniques
have been described to avoid this inconvenience (Soutar et al 1983, Fenton and Roberts
1985, McGregor 1987b, Bardsley et al 1990, Masser 1990, Liang et al 1994).
Another subsequent complication is the appearance of painful neuromas in the donor
area of the flap due to sectioning of sensory nerves (Boorman and Sykes 1987, Timmons
et al 1986).
It is also important to consider the appearance of the donor area. Flaps of identical
dimensions raised from the anterior region of the forearm are less visible than those
raised from the dorsal region. The more visible scar is therefore a result of a flap raised
from the posterior interosseous artery. From among the forearm flaps which produce less
visible donor scars, the first choice should be the ulnodorsal septocutaneous flap since it
is raised on the ulnar edge of the forearm—an area little exposed in the functional
position. The scar from raising a radial forearm flap on the radial side of the forearm is,
compared to similar areas, more visible than a scar resulting from raising an ulnar flap.
Any one of these flaps, if executed with reduced dimensions, which will permit the direct
closing of the donor area, will cause fewer visible scars.
The recurrent radial and ulnar flaps are useful for the reconstruction of areas in the
elbow and it is important to point out the fact that the arteries that nourish these flaps are
dispensable. When the flaps have small dimensions, it is possible to suture directly the
donor area minimizing the aesthetic sequelae more so, with the recurrent ulnar flap as its
donor scar is more concealed. For the reconstruction of large defects in the elbow it is
possible to use both flaps simultaneously.
Conclusion
In surgery of the hand, to reconstruct large cutaneous areas or in the case of simultaneous
cutaneous, osseous and tendinous reconstructions we prefer to use the radial forearm flap
as a fasciocutaneous, adipofascial or as a composite flap. For small areas localized
proximally in the hand and not over the metacarpophalangeal joints, we opt for the
ulnodorsal septocutaneous flap in which no important artery is sectioned. This flap
produces, from an aesthetic point of view, fewer donor scars in the forearm. Given the
importance of the ulnar artery in hand circulation and its proximity to the ulnar nerve,
ulnar forearm flaps are used only in selected cases in spite of the scars in the donor areas
being less visible. The posterior interosseous flap uses an artery that supplies almost all
muscles in the posterior compartment of the forearm. This is why the use of this flap
must be carefully thought out. The scar in the donor area of this flap is located in the
dorsal region of the forearm and, of all the flaps described, is the most visible amongst
those found in identical areas. We prefer to use the radial forearm flap and, for smaller
areas, the ulnodorsal septocutaneous flap. For reconstruction of the elbow we prefer the
recurrent ulnar flap if its donor scar will be less visible. If we need to reconstruct large
areas we use both the recurrent ulnar and the recurrent radial flaps.
References
Amarante J (1990) Retalhos Septocutâneos de Fluxo Invertido Contribuição Para o seu

Estudo a Nivel Distal dos Membros. Tese de doutoramento da Universidade do Porto:
Porto.
Amarante J, Costa H, Reis J, Soares R (1986) A new distally based fasciocutaneous flap
of the leg, Br J Plast Surg 39:338–40.
Amarante J, Costa H, Reis J, Soares R, Carvalho F (1987) Um novo conceito em cirurgia

plástica e reconstrutiva: retalhos venosos, (Prémio Pfizzer 1986), J Soc Cien Med
Lisboa 5:229–54.
Amarante J, Costa H, Reis J, Soares R (1988) Venous skin flaps: an experimental study
and report of two clinical distal island flaps, Br J Plast Surg 41:132–7.
Angrigiani C, Grilli D, Dominikow D, Zancolli E (1993) Posterior interosseous reverse
forearm flap. Experience with 80 consecutive cases, Plast Reconstr Surg 92:285–93.
Bardsley A, Soutar O, Elliot D, Batchelor G (1990) Reducing morbidity in the radial
forearm flap donor site, Plast Reconstr Surg 86:287–92.
Barreiro J, Huelin J (1980) Etude à l’aide de la radioanatomie de la vascularisation de
l’avantbras et de la main acquisitions récentes In: Tubiana R, ed. Traité de Chirurgie
de la Main. Vol 1. Masson: Paris, 332–49.
Becker C, Gilbert A (1988a) Le Lambeau cubital, Ann Chir Main 7:136–42.
Becker C, Gilbert A (1988b) Der Ulnaris-lappen, Handchir Mikrochir Plast Chir 20:180–
3.
Becker C, Gilbert A (1991) Lambeau des branches distales de l’artére cubitale et son
utilisation dans les récidives du canal carpian . In: Tubiana R, ed. Traité de Chirurgie
de la Main. Vol 4. Masson: Paris, 527–32.
Bellinger C, Smith J (1980) La vascularisation des nerfs du membre supérier. In: Tubiana
R, ed. Traité de Chirurgie de la Main. Vol 1. Masson: Paris, 371–5.
Bertelli JA (1993) Neurocutaneous axial island flaps in the forearm: anatomical,
experimental and preliminary clinical results, Br J Plast Surg 46:489–96.
Bertelli JA, Pagliei A (1998) The neurocutaneous flap based on the dorsal branches of the
ulnar artery and nerve: a new flap for extensive reconstruction of the hand, Plast
Reconstr Surg 101:1537–43.
Biemer X, Stock W (1983) Total thumb reconstruction: a one stage reconstruction using
an osteo-cutaneous forearm flap, Br J Plast Surg 36:55–9.
Boorman J, Sykes P (1987) Morbidity in the forearm flap donor arm, Br J Plast Surg
40:207–12.
Boyd B, Mulhollande S, Gullane P et al (1994) Reinnervated lateral antebrachial
cutaneous neurosome flaps in oral reconstruction. Are we making sense?, Plast
Braun F (1977) Le Lambeau antebrachial en ilot en chirurgie de la main. A propos d’une
série de 23 cas. Thése pour le Doctorar en Medicine. Université de Strasburg:
Strasburg.
Buchler U, Frey H (1991) Retrogade posterior interosseous flap, J Hand Surg 16A:283–
4.
Budo J, Finucan T, Clarke J (1984) The inner arm fasciocutaneous flap, Plast Reconstr
Surg 73:629–32.
Christie D, Duncan G, Glasson D (1994) The ulnar artery free flap. The first 7 years,
Plast Reconstr Surg 93:547–51.
Coleman S, Anson B (1961) Arterial patterns in the hand based upon a study of 650
specimens, Surg Gynecol Obst 113:409–24.
Costa M, Smith R, McGrouther DA (1988) Thumb reconstruction by the posterior
interosseous osteocutaneous flap, Br J Plast Surg 41:228–30.
Costa H, Comba S, Martins A, Rodrigues J, Reis J, Amarante J (1991) Further experience

with the posterior interosseous flap, Br J Plast Surg 44:449–55.
Culbertson J, Mutimer K (1987) The reverse lateral upper arm flap for elbow coverage,
Ann Plast Surg 18:62–8.
Daniel R, Terzis J, Schwarz G (1975) Neurovascular free flaps. A preliminary report,
Dolmann S, Guimberteau J, Baude J (1975) The upper arm flap, J Microsurg 1:162.
Elliot D, Bainbridge L (1988) Ulnar fasciocutaneous flap of the wrist, J Hand Surg
13B:311–15.
Emerson J, Sprigg A, Page R (1985) Some observations on the radial artery island flap,
Br J Plast Surg 38:107–12.
Fatah F, Nancarrow J, Murray D (1985) Raising the radial artery forearm flap: the
superficial ulnar artery trap, Br J Plast Surg 38:394–5.
Fenton O, Roberts J (1985) Improving the donor site of the radial forearm flap, Br J Plast
Surg 38:504–7.
Gelberman R, Blasingame J (1981) The timed Allen test, J Trauma 21:477–9.
Gelberman R, Nunley J, Koman L et al (1982) The results of radial and ulnar arterial
repair in the forearm, J Bone Joint Surg 64A:383–5.
Glasson D, Lovie M (1988) The ulnar island flap in hand and forearm reconstruction, Br
J Plast Surg 41:349–53.
Gottieb L, Levine L (1993) A new design for the radial forearm free-flap phallic
construction, Plast Reconstr Surg 92:276–83.
Guimberteau J, Goin J, Panconi B, Schmacher B (1988) The reverse ulnar artery forearm
island flap in hand surgery: 54 cases, Plast Reconstr Surg 81:925–32.
Holevich-Madjarova B, Paneva-Holevich E, Tjkarov V (1991) Island flap supplied by the
dorsal branch of the ulnar artery, Plast Reconstr Surg 87:562–6.
Hu W, Martin D, Foucher G, Baudet J (1994) Anterior interosseous flap, Ann Chir Plast
Esthet 39:290–300.
Huelin J, Barreiro F, Barcia E (1978) Etude radioanatomique des artéres interosseuses,
Acta Anat 102:147–58.
Kadry H, Hassan A, Tewfik O, Ismail M (1985) Recent fasciocutaneous flaps for repair
of post-burn neck, axillary and elbow contractures, Ann Medit Burns Club 2:89.
Katsaros J, Shusterman M, Bejju M (1984) The lateral upper arm flap anatomy and
clinical applications, Ann Plast Surg 6:489.
Koshima I, Moriguchi T, Etoh H, Tsuda K, Tanaka H (1995) The radial artery perforator
based adipofascial flap for hand coverage, Ann Plast Surg 35:474–9.
Lai M, Krishna B, Pelly A (1981) The brachioradialis myocutaneous flap, Br J Plast Surg
34:431.
Liang M, Swartz W, Jones N (1994) Local full-thickness skin-graft coverage for the
radial forearm flap donor site, Plast Reconstr Surg 93:621–5.
Lovie M, Duncan M, Glasson D (1984) The ulnar artery forearm free flap, Br J Plast
Surg 37:486–92.
Lutz BS, Wei FC, Chang SC et al (1999) Donor site morbidity after suprafascial
elevation of the radial forearm flap: a prospective study in 95 cases, Plast Reconstr
Surg 103:132–7.
Maillard G, Meredith P (1991) Bilateral pinch reconstruction. Versatility of the

Masquelet–Zancolli flap and the Wilkki operation, Plast Reconstr Surg 87:165–71.
Maruyama Y, Takeuchi S (1986) The radial recurrent fasciocutaneous flap: reverse upper
arm flap, Br J Plast Surg 39:458–61.
Maruyama Y, Onishi K, Iwahira Y (1987) The ulnar fasciocutaneous island, Plast
Reconstr Surg 79:381.
Masquelet A, Penteado C (1987) The posterior interosseous flap, Ann Chir Main 2:131–
9.
Masser M (1990) The preexpanded radial free flap, Plast Reconstr Surg 86:295–302.
McCormack L, Cauldwell E, Auson B (1953) Brachial and antebrachial arterial patterns,
Surg Gynecol Obstet 96:43–54.
McGregor A (1987a) The Allen test—an investigation of its accuracy by fluorescein
angiography, J Hand Surg 12B:82–5.
McGregor A (1987b) The free radial forearm flap. The management of the secondary
defect, Br J Plast Surg 40:83–5.
Meland N, Core Tg, Hoverman V (1993) The radial forearm flap donor site: should we
vein graft the artery? A comparative study, Plast Reconstr Surg 91:865–70.
Muhlbauer W, Herndl E, Stock W (1982) The forearm flap, Plast Reconstr Surg 70:336–
41.
Mutz S (1972) Thumb web contracture, Hand 4:236–9.
Nakajima H, Fujino T, Adachi S (1986) A new concept of vascular supply to the skin and
classification of the skin flaps according to their vascularization , Ann Plast Surg
16:1–11.
Niranjan N, Shibu M (1994) The median forearm flap, Br J Plast Surg 47:272–4.
O’Rahilly R (1986) Anatomy: A Regional Study of Human Structure. In: Gardner, Gray,
O’Rahilly, eds. WB Saunders Company: Philadelphia.
Parks B, Arbelaez J, Homer R (1978) Medical and surgical importance of the arterial
blood supply of the thumb, J Hand Surg 3B:383–5.
Parry S, Mathes S (1989) Blood supply of the upper extremity muscle as related to
functional tendon transfers, Clin Plast Surg 3:531–6.
Parry S, Ward J, Mathes S (1988) Vascular anatomy of the upper extremity muscles,
Penteado C, Masquelet A, Chevrel J (1986) The anatomic basis of the posterior
interosseous artery, Surg Radiol Anat 8:209–15.
Pinal F, Taylor G (1990) The venous drainage of nerves. Anatomical study and clinical
implications, Br J Plast Surg 43:511–20.
Reid C, Moss A (1983) One-stage flap repair with vascularised tendon graft in a dorsal
hand injury using the ‘Chinese’ forearm flap, Br J Plast Surg 36: 473–9.
Reis J, Malheiro E, Santa Comba A, Amarante J (1994) The ulnar superficial forearm
free flap. An alternative technique to the radial forearm flap. Proceedings of the 2nd
Congress Federation of European Society for Microsurgery, Copenhagen.
Revol M, Lantieri L, Loys S, Guerin-Surville H (1991) Vascular anatomy of the forearm
muscles. A study of 50 dissections, Plast Reconstr Surg 88:1026–33.
Reyes FA, Burkhalter WE (1988) The fascial radial arm flap, J Hand Surgery Am
13:432–7.
Schoofs M, Bovet J, Panconi B, Amarante J, Daoud G, Baudet J (1983) Le Lambeau

Chinois antebrachial technique et applications, Lille-Chirurgical 1:21–4.
Song R, Song Y, Yu Y, Song K (1982) The upper arm free flap, Clin Plast Surg 9:27–35.
Soutar D, Scheker L, Tanner N, McGregor I (1983) The radial forearm flap: a versatile
method for intra-oral reconstruction, Br J Plast Surg 36:1–8.
Stock W, Muhlbauer W, Biemer E (1981) Der neurovaskulare unterarm-insel-lappen,
Zeitschript Plastische Chirurgie 5:158–163.
Thatte R, Thatte M (1987) Cephalic venous flaps, Br J Plast Surg 40:16–19.
Timmons M, Missotten F, Poole M, Davies D (1986) Complications of radial forearm
flap donor sites, Br J Plast Surg 39:176–8.
Tonkin M, Stern H (1989) The posterior interosseous artery free flap, J Hand Surg
14B:215–20.
Yang G, Chen B, Gao Y (1981) Forearm free skin flap transplantation, Nat Med J China
61:139–42.
Weinzweig N, Chen L, Chen Z-W (1994) The distally based radial forearm
fasciosubcutaneous flap with preservation of the radial artery: an anatomic and clinical
approach, Plast Reconstr Surg 94:675–84.
Zancolli E, Agrigiani C (1986) Colgajo dorsal de antebrazo, Rev Assoc Argent Ortop
Traumatol 51:161–8.
3
Pedicled muscle and musculocutaneous
flaps
Christoph Heitmann and L Scott Levin
It was Sterling Bunnell who said that trauma to the limb involves all types of tissue,
irrespective of the divisions of surgical specialties that perform upper extremity surgery
(Bunnell 1970). Therefore we believe, among others, that the combination of specialties,
as represented in the orthoplastic approach, permits the best possible outcome in the
treatment of the mangled upper extremity (Green 1994, Gopal et al 2000). The
orthoplastic approach combines the best of two surgical specialists: the orthopedic
surgeon with training and practice traditionally dedicated to the care of bone and joint
injuries and the reconstructive plastic surgeon with expertise in soft tissue coverage and
resurfacing (Levin 1993). Many recent advantages in reconstructive surgery have
permitted greater salvage and more rapid restoration of the structure and function of
injured upper extremity (Vasconez 1993). Stabilization, fixation and distraction of bony
segments have been a key element in improving results. No less important has been the
demonstration that rapid and optimal soft tissue reconstruction has a direct impact on the
treatment of the limb as a whole.
The primary goal of upper extremity reconstruction is to provide key functions such as
sensory contact with the environment and the ability to manipulate objects. Described as
the extension of the brain, the hand is the focus of reconstructive efforts and because the
shoulder, arm and forearm permit the hand to accomplish all of its complex tasks, it is
important to maintain or restore their function. The mangled upper extremity is a
combination of injury to bones, joints, nerves and soft tissues. Skeletal stability is the
basis for all other reconstruction, the initial management of the fracture sets the stage for
subsequent events. It is beyond the scope of this chapter to go through all methods of
fracture stabilization.
Regardless what type of fixation is used, the importance of stable bone fixation must
be emphasized, because the vascular, functional and soft tissue reconstruction depend on
a stable skeleton. This chapter is limited to soft tissue coverage and reconstruction of the
shoulder and brachium because the focus is on pedicled muscle and musculocutaneous
flaps. The optimal timing of the soft tissue reconstruction in the severely traumatized
upper extremity remains controversial. The argument favoring staged procedures is the
need for a second look debridement (Gustilo et al 1990). If there is uncertainty about
traumatized and devascularized tissue, a second look is done to allow more adequate
debridement. The main argument for early reconstruction is to reduce the nosocomial
contamination and secondary necrosis of exposed tissues. Late soft tissue reconstruction
is associated with a significantly higher infection and flap complication rate when
compared with early (within 72 hours) soft tissue coverage (Hertel et al 1999). We
Pedicled muscle and musculocutaneous flaps 25
believe, that the overall timing of the soft tissue reconstruction should ideally be
immediate or as soon as possible. In questionable cases we use Godinas’s principles, a
second look and soft tissue reconstruction within 72 hours past the injury (Godina 1986).
Although various pedicled muscle and musculocutaneous flaps have been described for
soft tissue reconstruction of the shoulder and brachium (Palmer and Miller 1988,
Vasconez and Oishi 1993), we found almost all wounds to be manageable by either the
pedicled latissimus dorsi flap or its anterior homologue, the pectoralis major muscle flap.
There are certainly other choices, but these two flaps were found to have dependable and
consistent anatomy, long vascular pedicles, providing reliable and predictable results and
therefore becoming the workhorses of reconstructions for severe injuries to the shoulder
and brachium (Dowden and McCraw 1980, Stern and Carey 1988, Minami et al 1990).
Apart from traumatic soft tissue loss they are very useful in contaminated wounds of
the shoulder and in wounds caused by radiation. Ger, Chang and Mathes demonstrated
the value of muscle flaps in the treatment of osteomyelitis, which are more resistant to
bacterial infection and rapidly recover from inoculation with bacterial suspension (Ger
1977, Chang and Mathes 1982, Mathes et al 1982). This suggests that muscle flaps in
general are ideally suited for the treatment of osteomyelitic lesions. In addition, the
transposition of the latissimus dorsi has been used to restore flexion or extension of the
elbow (Hovnanian 1956, Zancolli and Mitre 1973). Furthermore, we have used transfer
of the latissimus and pectoralis major musculocutaneous flaps as an adjunct in the
treatment of patients who had chronic osteomyelitis and septic arthritis of the shoulder.
Surgical anatomy
Pedicled latissimus dorsi flap

Extensive experience with the latissimus dorsi has shown it to be perhaps the most
reliable and versatile of known flaps. It is the largest muscle in the body and is roughly
quadrangular in shape, originating from the lumbar fascia and posterior part of the pelvis
and inserting on the posterior aspect of the intertubercular groove of the humerus. Using
the latissimus dorsi flap has resulted in no major demonstrable functional deficit. Its
vascular supply is derived from the subscapular artery that bifurcates into the scapular
circumflex and thoracodorsal arteries. The thoracodorsal artery continues posteriorly and
inferiorly, giving off branches to the serratus anterior muscle. It enters the latissimus
muscle together with the thoracodorsal nerve and vein at a well-defined neurovascular
hilus, 2–3 cm medial to the lateral edge of the latissimus dorsi muscle and about 5 cm
distal to the inferior scapular border. A secondary blood supply comes from several small
perforator vessels along the spinous origin of the latissimus dorsi muscle. Based on the
thoracodorsal artery, the rotation point is predictably located near the apex of the axilla
posteriorly. This rotation point gives the flap an arc that allows it to reach the entire
shoulder posteriorly and the upper arm.
When the latissimus is used for reconstruction of the area of the upper arm and
shoulder, the patient is placed in the lateral decubitus position and the entire hemithorax
and the area of the arm that is to be reconstructed are prepared. The arm is left free to
facilitate exposure and mobilization of the flap. Every soft tissue reconstruction starts
with a thorough debridement and removal of all devitalized tissues from the area to be
reconstructed. After the debridement it can be decided whether a functional muscle
transfer, a muscle flap plus split thickness skin graft or musculocutaneous latissimus
dorsi flap is best suited for the existing defect. Horizontal incisions can be used to gain
access to the muscle, but a vertical incision is more direct and expedient. The incision
begins on the posterior aspect of the posterior axillary fold and is carried further parallel
to the main axis of the muscle fibers. The skin on either side is dissected off the muscle.
After the muscle is exposed, dissection is carried onto its undersurface, starting at the
axilla, with care taken to preserve the thoracodorsal artery on the undersurface of the
muscle. The latissimus dorsi muscle is elevated off the chest wall. It is best to first cut
distally along the iliac crest, which then gives better exposure for dividing the
attachments to the thoracolumbar fascia and scapula.
After the muscle has been fully elevated, the humeral insertion as well as the branch of
the thoracodorsal artery to the serratus muscle needs to be divided if the full arc of
rotation is required. For flap inset the latissimus dorsi muscle can be passed anteriorly to
the upper arm or the shoulder through a tunnel. If the tunnel is felt to be too tight full
extension of the incision to the defect is required to rule out compromise or torque of the
pedicle. When a flexorplasty is performed to restore elbow flexion, either the coracoid or
the acromion process is exposed by a deltopectoral incision, and the biceps tendon is
exposed by a separate incision distally. Both incisions are connected by means of a
subcutaneous tunnel situated on the anterior aspect of the arm. The former origin of the
latissimus dorsi muscle is passed through the tunnel and is sutured into the biceps tendon.
Next, the humeral insertion of the latissimus is fixed proximally to the coracoid or the
acromion. The upper extremity is immobilized with the elbow in 100° flexion and full
supination for 6 weeks in a posterior plaster splint. At this juncture active motion of the
shoulder motion and elbow is initiated. The latissimus dorsi muscle can as well be
utilized to restore elbow extension in cases of triceps palsy or traumatic loss of the triceps
muscle. The humeral insertion is left intact and the origin is sutured to the triceps tendon,
the periosteum of the olecranon and the connective tissue muscle septa on the extensor
surface of the forearm.
Pedicled pectoralis major flap

The pectoralis major muscle is located in the anterior chest wall and in many ways
matches the characteristics of the latissimus dorsi muscle. The pectoralis major is
particularly useful for the repair of anterior shoulder defects. The pectoralis can be
dissected out from beneath the skin, rotated into position, and split skin applied to its
exposed surface, or it can be used as a myocutaneous flap. The pectoralis muscle receives
its main blood supply from the thoracoacromial artery, a branch of the subclavian artery.
This main vascular axis runs on the undersurface of the pectoralis major muscle and can
be identified by Doppler preoperatively. In addition there are numerous perforating
vessels from the internal mammary artery.
For use in reconstruction of shoulder defects, the muscle can survive solely on the
thoracoacromial axis and the chest wall perforators can be safely divided. When elevated
upon the thoracoacromial axis, whether as a myocutaneous flap or as a muscle flap alone,
the pectoralis major has as its rotation axis a point 2 cm below and slightly medial to the
coracoid process. Swinging upon this axis, the tip of the flap can completely cover the
acromion, or head of the humerus. For flap harvest an oblique incision is marked from
the coracoid down to either side of the nipple. The skin on either side is then elevated off
the fascia of the pectoralis muscle. Once the entire muscle is exposed, dissection
proceeds around its lateral margin on the chest wall. Care is taken to leave the pectoralis
minor muscle and clavipectoral fascia intact. The fibers of origin of the pectoralis major
are dissected bluntly off the chest wall, dividing the perforating branches of the internal
mammary artery. When the pectoralis has been dissected free from the chest wall, it can
be elevated and rotated into place.
The effective length and reach of the flap is improved by dividing the insertion of the
pectoralis major muscle. The pectoralis major muscle is quite vascular and accepts a skin
graft readily. The donor wound can be closed primarily. If a skin component is
incorporated we prefer situating the skin island above the pectoralis muscle. The
pectoralis can also be used for biceps reconstruction, but requires lengthening of fascia to
reach the biceps tendon.
Illustrative case reports
Case 1
A 54-year-old patient presented with right elbow osteomyelitis and concomitant brachial
plexus palsy after a gun shot wound (Fig. 1a). The patient underwent repeated irrigation
and debridement including bony debridement with a high-speed burr until punctuate
bleeding (the socalled paprika sign) as an indication for healthy bone was obtained. The
soft tissue coverage was performed with a pedicled latissimus dorsi island flap (Fig. 1b–
d).
Case 2
A 36-year-old female patient was admitted for treatment of deep shoulder infection after
radiotherapy, chemotherapy and partial resection of the scapula, resection of the proximal
humerus and lateral clavicle (Tikhoff–Linberg resection) for a malignant ossifying
fibromyxoid tumor (Fig. 2a). During the tumor resection there was also involvement of
the brachial plexus, which had to
Figure 1
(a) Chronic right elbow osteomyelitis. (b) Flap design of a
pedicled latissimus dorsi flap. (c) Intraoperative view after
transposition of the latissimus dorsi island flap to the
elbow. (d) Result 6 months postoperatively.
be partially sacrificed. The shoulder wound was open for 6 months and the patient
suffered from constant pain. After thorough debridement the soft tissue defect at the
shoulder measured 5 × 12 cm and was closed with a pedicled latissimus dorsi island flap.
The patient is disease free since 18 months, shows no sign of infection and her pain status
was classified as mild (Fig. 2b).
Figure 2
(a) Deep right shoulder infection. (b) Result 18 months
after transposition of a pedicled latissimus dorsi island flap
providing stable soft tissue coverage.
Case 3
A 44-year-old patient had a severe, fulminant infection of the superficial fascia and
subcutaneous tissue known as necrotizing fasciitis of the right upper extremity. The
initial surgical incision revealed the pathognomonic liquefactive necrosis of the
subcutaneous tissue and fascia with the characteristic appearance of grayish, watery and
foul smelling fluid often referred to as ‘dishwater pus’. Immediate radical debridement
was carried out well beyond the margins of the cellulitis. Repeated debridement including
resection of the triceps muscle was warranted on a 12–24 hour
Figure 3
(a) Right upper extremity after repeated debridement in a
case of necrotizing fasciitis. (b,c) Result 6 months
postoperatively after restoration of the elbow extension
with a pedicled latissimus dorsi island flap.
basis until the infection was controlled and healthy muscle and fascia were reached (Fig.
3a). For functional restoration of the elbow extension a pedicled myocutaneous latissimus
dorsi flap was used. The residual defects have been addressed with split thickness skin
grafts (Fig. 3b,c).
Case 4
A 66-year-old male patient sustained a deep shoulder infection after rotator cuff repair.
The patient showed active drainage from an infected glenohumeral joint (Fig. 4a). After
debridement, the patient was left with a soft tissue defect located at the anterior aspect of
the shoulder, which was closed using a pectoralis major island flap (Fig. 4b). The flap
was harvested from distally to proximally and the skin island on top of the muscle was
rotated into the shoulder defect (Fig. 4c–f). Postoperatively the range of motion of the
shoulder was limited (Fig. 4g). The patient achieved 40° forward elevation, 30° lateral
elevation and 30° external rotation. However, 7 years after the operation the patient
showed stable wound coverage, there was no sign of infection and the patient was pain
free.
Figure 4(a,b)
(a) Infected right glenohumeral joint. (b) Flap design of a
pedicled pectoralis major flap.
Figure 4(c,d)
(c) Cranially reflected pectoralis major muscle with arrows
indicating the thoracoacromial pedicle and the pectoral
nerve. (d) Transposition of the island flap into the shoulder
defect.
Figure 4(e,f,g)
(e) Transposition of the island flap into the shoulder
defect. (f,g) Functional outcome 12 months
postoperatively.
Conclusion
Each year, millions of persons sustain injuries of varying degrees of severity to the upper
extremity. Orthopedic and plastic surgeons are frequently called on to treat these injuries.
Injuries to the upper extremity should be treated acutely, definitively, and
comprehensively. Collaboration between the orthopedic and plastic surgeons in the
treatment plan is essential if the patient is to obtain the best result. The transfer of the
pedicled latissimus dorsi flap and pectoralis major flap prove to be useful not only to
restore elbow flexion and extension but also provide regional coverage of the soft tissue
about the shoulder and brachium. In addition, we have successfully used both muscle
flaps as an adjunct in the management of chronic osteomyelitis and septic arthritis of the
shoulder and elbow.
References
Bunnell S (1970) Surgery of the Hand. JB Lippincott: Philadelphia.

Chang N, Mathes SJ (1982) Comparison of the effect of bacterial inoculation in
musculocutaneous and random pattern flaps, Plast Reconstr Surg 70:1–10.
Dowden RV, McCraw JB (1980) Muscle flap reconstruction of shoulder defects, J Hand
Surg 5A:382–90.
Ger R (1977) Muscle transposition for treatment and prevention of chronic post-traumatic
osteomyelitis of the tibia, J Bone Joint Surg 59A:784–91.
Godina M (1986) Early microsurgical reconstruction of complex trauma of the
extremities, Plast Reconstr Surg 78:285–92.
Gopal S, Majumder S, Batchelor AG, Knight AL, De Boer P, Smith RM (2000) Fix and
flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia,
J Bone Joint Surg 82B:959–66.
Green AR (1994) The courage to co-operate: the team approach to open fractures of the
lower limb, Ann R Coll Surg Engl 76:365–6.
Gustilo RB, Merkow RL, Templeman D (1990) Current concepts review: the
management of open fractures, J Bone Joint Surg 72A:299–304.
Hertel R, Lambert SM, Muller S (1999) On the timing of soft tissue reconstruction for
open fractures of the lower leg, Arch Orthop Trauma Surg 119:7–12.
Hovnanian AP (1956) Latissimus dorsi transplantation for loss of flexion or extension of
the elbow. A preliminary report on technic, Ann Surg 143:493–9.
Levin LS (1993) The reconstructive ladder. An orthoplastic approach, Orthop Clin North
Am 24: 393–409.
Mathes SJ, Alpert BS, Chang N (1982) Use of muscle flaps in chronic osteomyelitis:
experimental and clinical correlation, Plast Reconstr Surg 69:815–29.
Minami A, Ogino T, Ohnishi N, Itoga H (1990) The latissimus dorsi musculocutaneous
flap for extremity reconstruction in orthopedic surgery, Clin Orthop 260:201–6.
Palmer RS, Miller TA (1988) Anterior shoulder reconstruction with pectoralis minor
muscle flap, Plast Reconstr Surg 81:437–42.
Stern P, Carey JP (1988) The latissimus dorsi flap for reconstruction of the brachium and
shoulder , J Bone Joint Surg 70A:526–35.
Vasconez HC, Oishi S (1993) Soft tissue coverage of the shoulder and brachium, Orthop
Clin North Am 24:435–48.
Zancolli E, Mitre H (1973) Latissimus dorsi transfer to restore elbow flexion. An
appraisal of eight cases, J Bone Joint Surg 55A:1265–75.
4
Free flaps
Horacio Costa
Introduction
The anatomy of the upper limb allows the surgeon to design a variety of local, pedicle or
island flaps to cover small and median defects. For larger defects, it is necessary to use
flaps from distant donor sites.
The past two decades have seen major changes in reconstructive surgery of the upper
extremity (Buncke and Schulz 1966, Bunck et al 1966, Cobbett JR 1969, Ikuta et al 1976,
Yang and Gu 1979). The most important changes have been the timing of the
reconstruction and the quality of transferred tissues available. Following the description
of axial pattern flaps, the traditional teaching of length to breadth ratio in flap design
became obsolete (McGregor and Morgan 1973, Cormack and Lamberty 1984). Large
defects could thus be resurfaced immediately, but the hand still had to be attached to the
body. For many patients, this resulted in unnecessary joint immobilization, stiffness and
tenodesis.
The advantages of the free flap over the distant pedicle in upper limb reconstruction
are well documented. Free tissue transfers usually require only one operation and often
allow all other reconstructive procedures to be done in a single stage (Höpfner 1903,
Lapchinsky 1960, Komatsu and Taimai 1968, Biemer 1977a, Biemer and Duspira 1982,
Costa 1994). Free flaps bring new blood supply to the reconstructed area, whereas the
distant pedicle flap is parasitic on the recipient site after division of the pedicle. Free flaps
also allow elevation of the hand and immediate motion. Physical therapy is started as
soon as the patient recovers from anaesthesia, and reduces postoperative oedema and
stiffness. None of this is possible when pedicle flaps are used, as they restrict the mobility
of the hand and all joints proximal to the site of injury.
Pedicle flaps still play an important part in the reconstruction of the hand that is, to
provide extra skin cover. The groin flap fulfils an important role as a skin provider prior
to toe transfer in cases of extensive soft tissue loss on the hand. As a pedicle flap it does
not require dissection around the main arteries of the hand, which thus may be saved for
use when the toe or toes are subsequently transferred. Its donor site is inconspicuous, thus
it is a first choice in females. The distally based posterior interosseous fasciocutaneous
island flap also has all these advantages, except the donor site is not inconspicuous. It is
the author’s first choice for hand skin resurfacing (Fig. 1) (Costa and Soutar 1988, Costa
et al 1988, 1991, 1996, Costa 1994).
Principles of management
A complex injury to the upper limb can be defined as one that involves two or more
tissues of the limb and which jeopardizes upper limb function or survival. There are two
major dangers, which arise in the immediate post trauma phase. The first is
devascularization, which leads to necrosis and threatens the local survival of a particular
structure. The second is oedema and its inevitable sequela, stiffness, which may severely
impair the final functional result (Burke 1971, Robson et al 1974, Janzekovic 1975,
Nylen and Carlsson 1980). Microsurgery has proved to be a powerful tool in the
treatment of these two complications, by allowing arterial repair and hence
revascularization and also venous repair to improve circulatory return and help combat
oedema. The overall beneficial effects of improved vascularization include a favourable
influence on the healing of skin, bone, tendon, nerve and other structures (Costa 1994).
Figure 1(a–f)
Free flaps 37
Figure 1(g,h)
(a,b) Defect before and after debridement with exposed
bones. (c) Drawing of the distally based island flap. (d)
The flap is raised based on the septum between the
extensor carpi ulnaris and extensor digiti minimi. (e) The
distally based posterior interosseous island flap has been
transposed. (f) Postoperative appearance at 2 months
(proximal to injury zone, the radial artery is uninjured and
is available for late toe transfer). (g) Drawing of the second
toe transfer on the right foot. (h) The thumb reconstruction
after 3 months. Reproduced with permission of the Editor,
Eur J Plast Surg 1996; 19:92–6.
Immediate skin cover is preceded by thorough debridement of all dead tissue (Janzekovic
1975, Guofan et al 1981). The simplest method of obtaining skin cover is to use skin
grafts but this requires a vascularized bed and immobilization to allow a satisfactory graft
to take. Regional arm and forearm flaps have revolutionized skin cover of the upper
extremity and form part of the reconstructive armamentarium. The main indications for a
free flap in upper extremity reconstruction are where no local or regional flap can be
used, extensive lesions of the arm, forearm and hand. Where specific large tissue losses
are present the free flaps can be used as functional muscle, tendons, nerves, bone and
fingers (Costa 1994).
Many free flaps are available for use in reconstruction of the upper extremity.
Choosing a flap with minimum donor site morbidity is a primary consideration in
reconstructive surgery. With the current variety of free flaps, coverage may be tailored to
the needs of the upper extremity recipient site, matching soft tissue, skin thickness,
texture and colour.
Thus, the defect to be reconstructed must be assessed for its need for bulk and surface
cover. The selection of the flap will be governed, in part, by this assessment. In general,
muscle flaps are used when defects require a relatively large volume flap and fascial and
fasciocutaneous flaps are used to provide less bulky surface cover or a functional
reconstruction.
Muscle and musculocutaneous flaps (Table 1)
These have the advantage that they can be placed between structures, thus filling what
otherwise would be dead space. They well vascularize the areas in which they are placed
and are helpful in treating both acute defects and defects left by debridement of bone
following chronic osteomyelitis (Mathes and Nahai 1982). The muscle tissue is also quite
useful for transfer as a functioning unit when microneurovascular anastomoses are
performed (Fig. 2f–h) (Ikuta et al 1976, Manktelow and McKee 1978, Schenk 1978,
Mathes and Nahai 1982).
Fascial and fasciocutaneous flaps (Table 2)
These are excellent for coverage of large surfaces, although they lack the bulk to fill dead
space. They result in minimal donor site morbidity and do not restrict range of motion in
the
Table 1 Musculocutaneous free tissue transfers.

Site Latissimus Serratus Rectus Tensor
Gracilis
dorsi anterior abdominis fascia lata
Muscle size 25 × 35 12 × 10 5 × 20 5×5
6 × 30
(cm)
Skin territory 30 × 40 12 × 5 14 × 25 8 × 30
8 × 15
(cm)
Pattern of Dominant Two Two Dominant
Dominant
blood supply pedicle and dominant dominant pedicle
pedicle and
secondary pedicles pedicles
minor
segment
pedicle
pedicles
Vessel Thoracodorsal Lateral Superior Lateral
Medial
artery and vein thoracic/ epigastric/ circumflex
circumflex
thoracodorsal inferior branch of
femoral
epigastric profunda
artery
femoris
Pedicle 9.3 8/9.3 3.5/4 6
5
length (cm)
Calibre 2.7 2.5/2.7 2/2.2 1.8
1.5
(mm)
Sensory Segmental Segmental Segmental Lateral Medial
nerve intercostal, T2– intercostal, femoral cutaneous
T6 T2–T4 cutaneous of thigh
Free flaps 39
Motor nerve Thoracodorsal Long thoracic Segmental Superior Anterior

gluteal branch of
obturator
Nerve length 12.3 10 5
5
(cm)
Osseous None 6th, 7th ribs None Iliac crest
None
territory
Accessibility Good Fair Fair Good Good
Donor site Not important Adduction of Abdominal Minimal
Not
function loss scapula wall
important
strength
Donor site Good to fair Good Good Fair
Good
appearance
Table 2 Fasciocutaneous free tissue transfers.

Site Temporal Scapular Lateral Radial Dorsalis First web Second toe
fascia arm forearm pedis space of
foot
Skin 7 × 7 (deep 12 × 8 10 × 6 20 × 10 6 × 9 (11 6 × 3 (14 5 × 6 (length
territory fascia), 14 × 9) × 7.5) and
(cm) × 12 circumference
(superficial of toe)
fascia)
Pattern of Dominant Dominant Dominant Dominant Cutaneous Cutaneous Two
blood supply pedicle cutaneous and pedicle pedicle pedicle cutaneous
pedicle secondary (flow- pedicles
cutaneous through)
pedicle
(flow-
through)
Vessel Superficial Circumflex Profunda Radial Dorsalis First First dorsal
temporal scapular brachii artery pedis dorsal metatarsal
artery (posterior artery metatarsal and plantar
radial artery digital
collateral) arteries
Pedicle 2.5 6 5 10 15 7.4 7.4/3
length (cm)
Calibre 1.6 1.8 1.5 2.5 1.5 1.3 1.3/1.2
(mm)
Sensory None Segmental Posterior Medial Superficial Deep Superficial
nerve intercostal cutaneous and peroneal peroneal and deep
of arm lateral peroneal,

cutaneous plantar digital
of
forearm
Osseous None Lateral Lateral Distal Second None Toe
territory border of aspect of radius metatarsal phalanges
scapula humerus (10 × 1
(10 × 1 cm)
cm)
Accessibility Good Good Good Good Good Good Good
Donor site None None None None Minimal Minimal Sport
function loss activities,
long walks
Donor site Good Good Fair Fair Fair Good Good
appearance
Free flaps 41
Figure 2
(a) Crush-degloving injury, involving the anterior aspect of
the left forearm, with loss of skin, flexor muscles, radial
and ulnar arteries, median and ulnar nerves and an
ischaemic hand. (b) Marking of the flow-through radial
flap. (c) Raised flap, including palmaris longus (PL)
tendon. (d) Transposed flap after proximal and distal
arterial and venous anastomoses have been performed. The
arrow points to the thrombosed interpositional reversed
saphenous graft to the ulnar artery. (e) Appearance at 4

months after surgery illustrating viability of the flap and
the hand. (f,g) Drawing and harvesting of the free
functional muscle transfer. (h) Appearance at 7 months
after surgery. Already the patient has a useful grip
capacity. Reproduced with permission of the Editor, Eur J
Plast Surg 1991; 44:533–7.
majority of cases (Fig. 3) (Lamberty and Cormarck 1983, Cormarck and Lamberty 1984).
Osteomyofasciocutaneous flaps
These have specific indications for reconstruction of bone defects in the upper limb.
These include the length of the defect, quality of surrounding soft tissue, malignancy
(where chemotherapy or irradiation may be considered postoperatively and it is essential
to maintain bone support while awaiting union and hypertrophy) and a record of prior
failed conventional bone grafting techniques.
Any long bone defect exceeding 8–10 cm in the upper limb should be considered for
reconstruction by vascularized bone transfer. Shorter defects may warrant consideration
if there are additional factors such as a poor surrounding soft tissue milieu due to prior
infection or multiple surgical procedures.
Management of extraarticular long bone defects in the upper extremity may be
amenable to a variety of reconstructive measures including shortening, cancellous or
corticocancellous autografts, synostosis, bone transport, vascularized bone grafts,
diaphyseal allografts and metallic prosthetic replacement. Shortening and bone grafting
in some form are the most widely applied techniques (Allien et al 1981, Dell and
Sheppard 1984).
The choice of the bone free flap is not a difficult task, since for the overwhelming
majority of upper limb bone defects (for which a microvascular bone graft is indicated)
the fibula is the preferred donor bone. A number of factors favour the fibula. A length of
up to 30 cm can be obtained and the diameter of the fibula approximates that of the radius
and ulna. For humerus reconstruction the fibular diameter permits intramedullary
placement and demonstrates the ability to hypertrophy to the size of the diaphysis of the
humerus. The cortical structure of the fibula permits excellent internal fixation potential
with plates and/or screws. For radius and ulnar reconstructions, the fibula has a similar
diameter to the diaphyses of the forearm bones. Frequently, for radius reconstruction the
distal fibula end may be impaled into the distal radius metaphyseal flare (Pho 1979,
Weiland et al 1979, Wood 1987, Zhong-Jia 1987). The anterior iliac crest based on the
deep circumflex iliac vessels may occasionally be useful for reconstruction near the distal
metaphysis of long bones or for reconstruction of a bony defect in the carpus. The author
has encountered a situation of extensive carpal osteomyelitis where, after total bone
carpal removal, a vascularized anterior iliac crest free flap was successfully transferred.
Free flaps 43
Emergency free flaps
The concept of emergency free tissue transfer was developed by Marko Godina (1986).
In a series of 134 upper and lower limb traumatic injuries, 80% of the flaps were
transferred immediately following the patient’s admission to hospital and 20% within 72
hours after injury, so defining the group of early free flaps. Lister and Scheker (1988)
defined the emergency free flap as the flap transferred for coverage of soft tissue defects
at the time of the first surgical procedure and during the first 24 hours after injury.
The idea that the probability of failure of free tissue transfer is greater if done as an
emergency procedure, still exists. Godina’s experience clearly demonstrated the
opposite—his failure rate in 134 emergency and early free flaps transfers was 0.75%,
compared with a 12% failure rate observed in his series of 167 delayed reconstructions
(Godina 1986). Lister and Scheker (1988) reported 6.05% failure rate in 31 emergency
free flaps; Arnez (1993) reinforced the concept with his 3% failure rate in 100 emergency
free flaps. Costa et al (1997a) report a series of nine acute free flaps in head, upper and
lower limb injuries with no postoperative infections and no failures, definitively
confirming the reliability of the free flap concept. Combined orthopaedic and plastic
surgery teams dealing with major trauma must follow strict principles of management to
develop the most efficient approach for extensive wounds with large zones of injury.
The first aim is to control infection and the principle is radical debridement
(Janzekovic 1975, Haury et al 1978). Infection is present in granulation tissue which is
poorly penetrated by systemic antibiotics (Burke 1971, Robson et al 1974). Nylen and
Carlsson’s study, on upper extremity trauma treated with a conservative approach and
serial debridement, had a 52% infection rate, while Godina reported a 17.5% infection
rate during treatment of 167 grade III traumatic injuries on both lower and upper
extremities (Nylen and Carlsson 1980, Godina 1986). The infection rate in 134, 31, 100
and 9 patients dropped drastically to 1.5% (Godina 1986), 9.7% (Lister and Scheker
1988), 2% (Arnez 1993) and 0% (Costa et al 1997a) respectively when these authors
analysed their series of radical debridement and emergency free flap reconstructions.
Figure 3
(a) Crush-degloving injury involving the dorsum of the left
hand, with loss of skin and extensor tendons of the index,
middle, ring and little fingers with tangential bone losses
of the 2nd and 3rd metacarpal bones in a dental surgeon.
(b) Marking of the tendofasciocutaneous dorsalis pedis
flap on the dorsum of the left foot. (c) Raised flap,
including long extensor tendons of the 2nd, 3rd, 4th and
5th toes, great saphenous vein, dorsalis pedis vessels and
superficial peroneal nerve. (d–f) Appearance at 13 months
after surgery. Good functional result of extension and
flexion of the fingers. Good cosmetic result due to the
similarities of the skin between the dorsum of the foot and
hand.
Open wounds are subject to further loss of tissues and extension of the zone of injury
due to bone and tendon desiccation and formation of granulation tissue (Godina 1986,
Free flaps 45
Lister and Scheker 1988, Arnez 1993, Costa et al 1997a). The best surgical exposure of
the whole wound is possible immediately after radical debridement, when there is no
tissue fibrosis, friability or granulation, no anatomical structures displacement by wound
contracture and no retraction of recipient blood vessels which still have integrity of their
walls. For these reasons the success rate is higher in all series of emergency and early
free flap transfers compared with the series of serial debridement and delayed wound
closure.
Nowadays, free tissue transfer is not a lengthy and unpredictable procedure. The entire
initial procedure, which always includes debridement and frequently bone fixation,
tendon repair, revascularization and even nerve grafting, should average under 5 hours
for small defects, under 8 hours for medium defects and under 12 hours for large defects
(Lister 1988, Lister and Scheker 1988). In our series, the longest procedures were all
related to the flow-through radial midforearm flaps for coverage–revascularization and
coverage–reimplantation, taking on average 10 hours. The total operating time per patient
is in fact reduced, since the main reconstruction is accomplished in a single big operative
procedure. Our shortest operative procedures took 7 hours (Costa et al 1997a).
Cost effectiveness should also be considered. In Godina’s series the average length of
hospital stay was 27 days and the average number of operations was 1.3 per patient
(Godina 1986). In Lister and Scheker’s (1988) series of upper extremity injuries the
average hospital stay was 11.8 days and 27 out of 31 patients returned to work, 18 of
them to their previous employment. In Arnez’s (1993) series of 100 emergency free flaps
the hospitalization ranged between 14 to 25 days. In our series the average hospital stay
was 27.8 days (range 20–44 days) and the average number of operations was 2 per patient
(Costa et al 1997a).
Age is not a contraindication for the use of acute free flaps as clearly demonstrated by
Lister (1988); the youngest patient on whom this author has performed an early free flap
was 2.5 years old, the oldest was 76 and both did well. This point is also reinforced by
our series in which the youngest patient was 4 years old and the oldest 65 (Costa et al
1997a).
Thus, emergency free flaps have proved to be a more reliable technique than delayed
wound closure, offering the patient an effective method of reconstruction with significant
advantages in postoperative form and function.
One-stage coverage and revascularization of traumatized limbs by a flow-

through radial mid-forearm free flap
On analysing all the described axial flaps, one finds that few have the capacity to allow a
flowthrough circulation. The theoretical idea of flow-through circulation was suggested
by Soutar et al (1983) for head and neck reconstruction, that is, establishing an
uninterrupted arter ial flow through a flap between the external carotid and distal facial
artery. It was also suggested by Cormack and Lamberty (1984) with the use of Siamese
or sister flaps in which a flap could be attached onto the end of another flap.
Lamberty and Cormack (1983) reported one clinical case of head and neck
reconstruction in which they used an antecubital fasciocutaneous free flap to reconstruct
an excisional defect after removal of a squamous cell carcinoma, involving the left pinna
and external auditory meatus. The proximal end of the divided facial artery was
anastomosed to the proximal end of the radial artery and the distal end of the radial artery
was looped back to be anastomosed to the distal end of the facial artery. The flaps which
were considered suitable for this were the antecubital forearm flap (Lamberty and
Cormack 1983) and the radial forearm flap (Lamberty and Cormack 1983, Soutar et al
1983). Costa et al (1991b) described the practical use of this concept in two clinical cases
(hand and foot) in which uninterrupted arterial and venous flow was established through
the radial mid-forearm fasciocutaneous flap, allowing revascularization of the ischaemic
extremity (Fig. 4).
The clinical importance of this concept is paramount. Exposure of deep structures, like
tendons, nerves and/or bone with vascular damage which often accompanies major
trauma of the extremities, may warrant flap cover with its own blood supply. If the
clinical situation is complicated by ischaemia of the distal segment (hand or foot), we are
dealing with a double problem of coverage and revascularization. In this type of situation,
the choice of soft tissue reconstruction is not just dependent on the immediate problem of
wound closure, the quality of the soft tissue cover or the possibilities of subsequent
reconstruction, but we must also consider the vascular pattern of the flap to be used,
allowing a flow-through circulation to achieve a one-stage technique of soft tissue
coverage and distal revascularization, without having to resort to an interpositional
reversed vein graft to bridge the vascular gap (see Fig. 2).
The radial forearm flap is based on the radial artery which is included in a
condensation of the deep fascia, called the lateral intermuscular septum of the forearm.
The radial mid-forearm flap combines the advantages of easy dissection, is hairless, has
thin skin and provides a suitable bed for grafting, inclusion of bone and, most
importantly, the possibility to dissect proximal and distal vascular pedicles allowing a
flowthrough circulation to be established. Another advantage is that either the venae
comitantes or a superficial vein, or both, may be used to drain the flap and the distal
revascularized segment of the extremity; this double venous drainage system of the flap
links the superficial and deep venous systems of the reconstructed extremity. We believe
that this technique achieves, possibly, the most physiological reconstruction in these
clinical situations.
The antecubital fasciocutaneous flap based on the inferior cubital artery, a branch of
the radial artery, has been described by Lamberty and Cormack (1983); it was classified
as a type B modified fasciocutaneous flap (Cormack and Lamberty 1984). Its essential
characteristic is the T-junction between the pedicle and the radial artery which enables a
much longer distal arterial pedicle to be dissected; another advantage is that the length of
the pedicle is independent of the flap length whereas in the radial forearm flap the length
of the pedicle is inversely related to the size of skin flap. However, two major draw
Free flaps 47
Figure 4
Diagram showing the anatomical and dynamic concept of
a flowthrough fasciocutaneous free radial mid-forearm
flap; a, superficial vein; b, venae comitantes; c, radial
artery; and d, lateral fascial intermuscular septum of the
forearm.
backs exist with this flap: the absence of a significantly sized inferior cubital artery and
the type C variety of this flap in which the vessel arises from the radial recurrent artery
which has its point of origin from the brachial artery.
Other axial flaps may be used to put this dynamic concept of flow-through circulation
into practice. The lateral arm flap is based on the posterior radial collateral artery, which
is a branch of the profunda brachii artery and has been described by Song et al (1982) and
Katsaros et al (1984). This flap has a shorter and thinner pedicle, particularly distally
where its artery anastomoses with the recurrent interosseous artery, and its elevation is
more difficult compared with the radial forearm flap. While it would probably be possible
to use this flap as a flowthrough flap, this has not been reported to our knowledge. The
ulnar forearm flap is based on the segment of the ulnar artery distal to the common
interosseous branch and has been described by Lovie et al (1984); many of its properties
are shared with the radial flap although with some advantages: less hairy territory, less
obvious donor site and, more importantly, when the flexor carpi ulnaris muscle is
included in the flap, it may be used to fill cavities. On the other hand, disadvantages are
also present, such as a slightly more difficult dissection and the danger of
devascularization of the ulnar nerve.
In conclusion, the flow-through concept is of considerable use in the field of major
trauma of the extremities where compound tissue losses are combined with
devascularization of the distal segment. The free flaps which offer adequate
characteristics for this vascular achievement are the radial forearm, the ulnar forearm, the
antecubital forearm and the lateral arm fasciocutaneous flap, although we believe the
advantages of the mid-forearm radial flap outweigh those of the other flaps.
The flow-through free flap in reimplantation surgery

Reimplantation and revascularization of extremities continue to be demanding tasks for
the plastic and reconstructive surgeons. Their need increases in proximal, total or subtotal
amputations, because of loss of length. If we are dealing with avulsion type injuries, the
major pitfall is the extent of vessel damage both in the proximal amputated stump, and in
the distal amputated part. Consequently, vascular anastomosis must be performed as far
proximally and distally, requiring greater bone shortening or longer interposition vein
grafts.
Biemer (1993) defined replantation as the operative reconstruction of amputation
injuries, including the reconnection of various structures, including the blood vessels
which will guarantee the viability of the amputated part. Since the introduction of vein
grafts by Biemer (1977b), replantation and revascularization has become possible in
avulsion and heavy combined crushing injuries allowing re-anastomosis through a
Figure 5
Diagram showing the anatomical and dynamic concepts of
flowthrough fasciocutaneous free flaps in replantation.
bridge over and out of the zone of trauma. Nowadays, they play a major role in
replantation surgery. However, this useful technique does not have soft tissue coverage
capacity which is paramount in certain types of replants. Costa et al (1997b) described
the practical use of the flowthrough free flap concept in hand replantation (Fig. 5).
Considering the main vascular pedicles, we have two kinds of situation: (1) the
absence of major longitudinal losses of the vessel ends, allowing end to end anastomosis
with some bone shortening and (2) the presence of major longitudinal losses of the vessel
ends making techniques for their reconstruction the key point for re-establishment of
blood flow.
Bone shortening is limited, particularly in the lower limb to a maximum of 5–6 cm
and can be performed either proximally in the amputated stump or distally in the
amputated part. Interpositional vein grafts are the method of choice to bridge the vascular
gaps and are usually harvested from the great and small saphenous, cephalic and basilic
veins or their tributaries, depending on the length of the vascular defect and the diameter
of the vessels. Biemer and Duspiva (1982) list the following indications for vein grafts.
• vessel defects (arterial and venous)
• difficult anastomoses with short vessel stumps
• to bypass bifurcation and tributaries
Free flaps 49
• tension at the site of anastomosis

• differing vessel calibres.
In major trauma of the extremities, including total and subtotal amputations, flap cover is
desirable when exposure of deep structures like tendons, nerves and/or bone is present
(ZhongJia 1987, Costa et al 1997a). In these clinical situations the flow-through free flap
concept is the method of choice (Costa 1991). There are two types of free flap which
allow the clinical application of this concept in replantation surgery.
1. The flow-through free fasciocutaneous flap for arterial supply and venous drainage of
the replant (Fig. 6).
2. The flow-through free venous flap for venous drainage of the replant (Fig. 7).
The flow-through free fasciocutaneous flap is a one-stage technique of soft tissue cover
and distal revascularization. This technique has other important advantages:
• Reconstruction of the arterial defect by another artery.
• Reconstruction of the superficial and deep venous systems by the superficial and deep
veins of the flap.
• Anatomical link between superficial and deep venous systems through the flap.
• Maintenance of the collateral vessels in the traumatic defect by the flap tissue.
• No major discrepancies in the microvascular anastomosis.
The flow-through venous flap also is an interesting and evolutionary concept. Baek et al
(1985) and Amarante et al (1988) presented experimental work in the dog, testifying the
viability of the flow-through venous saphenous flap. Successful clinical cases have been
reported and Honda et al (1984) have used skin and subcutaneous tissue as free venous
carriers for digital replants, including dorsal skin losses with success in two out of five
cases (Dell and Sheppard 1984, Honda et al 1984, Chavoin et al 1987, Thatte and Thatte
1987, Amarante et al 1988).
A recent finding must be brought into the discussion about the survival of these flow-
through venous flaps. The experimental work of Noreldin et al (1992) has confirmed the
importance of the
Figure 6
(a,b) Oblique transcarpometacarpal amputation of the left
hand (palmar and dorsal aspects). (c) The crush-degloving
injury of the amputated stump. (d) Bone fixation of the
amputated part without bone shortening. The segmental
injury of the radial vessels is shown between arrows. (e)
Marking of the flow-through fasciocutaneous radial flap.
(f,g) Harvesting of the free flap. (h) Appearance at 4
months after surgery. Already, the patient has a useful grip
capacity. Reproduced with permission of the Editor, Eur J
Plast Surg 1997; 20:181–5.
Free flaps 51
Figure 7
(a) Transmetacarpal amputation of right hand. (b) Dorsal
aspect of the amputated stump with skin loss and absence
of dorsal veins. (c) Palmar aspect of the amputated stump
with skin incisions for dissection of the radial artery and
harvesting of the basilic vein graft. (d) The free dermal
flow-through venous flap. (e) Immediate postoperative
result with split graft applied over the flap. (f–h)
Appearance at 5 months after surgery. A good range of
motion was achieved with a useful grasp. Reproduced with
permission of the Editor, Eur J Plast Surg 1997; 20:181–5.
perivenous areolar tissue in perfusion of the skin island in the rat inferior epigastric
venous flap. Shalaby and Saad (1993) presented histological studies of the pedicles of
long and short saphenous and cephalic venous flaps in fresh human cadavers and in two
clinical cases, showing that one or two arterioles and multiple capillaries were present in
the perivenous areolar tissue. Lenoble et al (1993) showed experimentally the incapacity
for a vein to nourish a flap in the epigastric and thoraco-abdominal flow-through venous
flaps of the rat, if the vein was meticulously cleaned of the perivenous areolar tissue. The
authors concluded that the survival observed in clinical reports could be explained by the
simultaneous preservation of arterial microcirculation in the perivenous fat, augmentation
of blood flow and pressure and by exchanges with the recipient bed. This challenges the
concept that these flaps are purely venous. These explanations seem to be supported by
Chow et al (1992).
Sequentially linked free flaps are a very interesting and useful concept. The complex
threedimensional nature of composite head and neck defects after tumour extirpation may
challenge the ability of any single osteocutaneous flap to adequately reconstruct all
aspects of the resultant defect. Sequentially linked free flap reconstructions, consisting of
one free flap linked to the second, have become a preferred method of reconstruction for
complex composite head and neck defects when there is limited recipient site vascularity
(Sanger et al 1990, Wells et al 1994).
Acknowledgement
The author would like to thank his wife, Fernanda Zenha for her help and encouragement
to accomplish this work, and for typing the manuscript and the line drawings.
References
Allien Y, Gomis R, Yoshimura M, Dimeglio A, Bonnel F (1981) Congenital

pseudarthrosis of the forearm. Two cases treated by free vascularised fibular graft, J
Hand Surg 6:475–81.
Amarante J, Costa H, Reis J, Soares R (1988) Venous skin flaps: an experimental study
and report of two clinical distal island flaps, Br J Plast Surg 41:132–7.
Arnez ZM (1993) Acute free flaps. In: Soutar D, ed. Microvascular Surgery and Free
Tissue Transfer. Edward Arnold: London, 140–51.
Baek SM, Weinberg H, Song Y, Park CG, Biller HF (1985) Experimental study of the
survival of venous island flaps without arterial inflow, Plast Reconstr Surg 75:88–95.
Biemer E (1977a) II. Zehentransplantation. Vortrg auf Third Congress of European
Section of the International Confederation for Plastic and Reconstructive Surgery: The
Hague, May 22–27.
Biemer E (1977b) Vein grafts in microvascular surgery, Br J Plast Surg 30:197–201.
Biemer E (1993) Current status of replantation surgery. In: Soutar D, ed. Microvascular
Surgery and Free Tissue Transfer. Edward Arnold: London, 43–53.
Biemer E, Duspiva W (1982) Reconstructive Microvascular Surgery. Springer-Verlag:
Berlin.
Free flaps 53
Buncke HJ, Schulz WB (1966) Total ear reimplantation in the rabbit utilizing micro-
miniature vascular anastomoses, Br J Plast Surg 10:15–22.
Buncke HJ, Buncke CM, Schulz WB (1965) Experimental digital amputation and
reimplantation, Plast Reconstr Surg 36:62.
Buncke HJ, Buncke CM, Schulz WB (1966) Immediate Nicoladoni procedure in the
Rhesus monkey, or halluxto-hand transplantation, utilizing microminiature vascular
anastomoses, Br J Plast Surg 19:332–7.
Burke JF (1971) Effects of inflammation on wound repair, J Dent Res 50:296–302.
Chavoin JP, Rouge D, Vachand M, Boccalon H, Costaglioga M (1987) Island flaps with
an exclusively venous pedicle. A report of eleven cases and a preliminary
haemodynamic study, Br J Plast Surg 40:149–54.
Chow SP, Chen DZ, Gu YD (1992) A comparison of arterial and venous flaps, J Hand
Surg 17B:359–64.
Cobbett JR (1969) Free digital transfer: report of a case of transfer of a great toe to
replace an amputated thumb, J Bone Joint Surg 51B:677–9.
Cormack GC, Lamberty BGH (1984) A classification of fasciocutaneous flaps according
to their patterns of vascularisation, Br J Plast Surg 37:80–7.
Costa H (1994) Estudo anatómico e aplicações clínicas de retalhos livres microcirúrgicos,
Tese de Doutoramento, Universidade do Porto.
Costa H, Soutar DS (1988) The distally based island posterior interosseous flap, Br J
Plast Surg 41:221–7.
Costa H, Smith R, McGrouther DA (1988) Thumb reconstruction by the posterior
interosseous osteocutaneous flap, Br J Plast Surg 51:228–33.
Costa H, Comba S, Martins A, Rodrigues J, Reis J, Amarante J (1991a) Further
experience with the posterior intereosseous flap, Br J Plast Surg 44:449–55.
Costa H, Guimarães I, Cardoso A, Malta A, Amarante J, Guimarães F (1991b) One-
staged coverage and revascularisation of traumatised limbs by a flow-through radial
mid-forearm free flap, Br J Plast Surg 44:533–7.
Costa H, Cunha C, Silva A, Malheiro E, Luz M, Guimarães I, Conde A, Cardoso R
(1996) One real advantage of the distally based posterior interosseous island flap, Eur
Costa H, Cunha C, Cardoso A, Bardsley A (1997a) Emergency free tissue transfer, Eur J
Costa H, Cunha C, Conde A, Barsdley A, McGrouther DA (1997b) The flow-through
free flap in reimplantation surgery: a new concept, Eur J Plast Surg 20:181–5.
Dell PC, Sheppard JE (1984) Vascularised bone grafts in the treatment of infected
forearm non unions, J Hand Surg 9:653–8.
Foucher G, Norris RW (1988) The venous dorsal digital island flap or the neutral flap, Br
Guofan Y, Baoqui C, Yuzhi G (1981) Forearm free skin flap transplantation, Natl Med J
China 61:139.
Haury B, Rodeheaver G, Vensko J et al (1978) Debridement: an essential component of
traumatic wound care, Am J Surg 135:238–42.
Honda T, Nomura S, Yamanchi S, Shimamura K, Yoshimura M (1984) The possible

applications of a composite skin and subcutaneous vein graft in the replantation of
amputated digits, Br J Plast Surg 37:607–12.
Höpfner E (1903) Über GefäBnaht, GefäBtransplantation und Reimplantation von
amputierten Extremitäten, Arc Klin Chir 70:417–22.
Ikuta W, Kubo T, Tsuge K (1976) Free muscle transplantation by microsurgical
technique to treat severe Volkmann’s contracture, Plast Reconstr Surg 58: 407–11.
Janzekovic A (1975) The burn wound from a surgical point of view, J Trauma 15:42–6.
Katsaros J, Schusterman M, Beppu M, Banis JC, Acland RD (1984) The lateral upperarm
flap: anatomy and clinical applications. Ann Plast Surg 12:489–500.
Komatsu S, Taimai S (1968) Successful replantation of a completely cut-off thumb, Plast
Lamberty BGH, Cormack GC (1983) The antecubital fasciocutaneous flap, Br J Plast
Surg 36:428–33.
Lapchinsky AG (1960) Recent results of experimental transplantation of preserved limbs
and kidneys and possible use of this technique in clinical practice, Ann NY Acad Sci
64:539.
Lenoble E, Foucher G, Voisin MC, Maurel A, Gontallier D (1993) Observations on
experimental flow-through venous flaps, Br J Plast Surg 46:378–83.
Lister G (1988) Emergency free flaps. In: Green DP, ed. Operative Hand Surgery, 2nd
edn. Churchill Livingstone: Edinburgh, 1127–49.
Lister G, Scheker L (1988) Emergency free flaps to the upper extremity, J Hand Surg
13A:22–9.
Lister GD, Kalisman M, Tsai TM (1983) Reconstruction of the hand with free
microneuro-vascular toe-to-hand transfer: experience with 54 toe transfers, Plast
Lovie MJ, Duncan G, Glasson DW (1984) The ulnar artery forearm free flap, Br J Plast
Surg 37:486–92.
Manktelow RT, McKee NH (1978) Free muscle transplantation to provide active finger
flexion, J Hand Surg 3:416–26.
Mathes SJ, Nahai F (1982) Clinical Applications for Muscle and Musculocutaneous
Flaps. CV Mosby Company: St Louis.
May JW, Chait LA, Cohen BE, O’Brien B McC (1977) Free neurovascular flaps from the
first web of the foot in hand reconstruction, J Hand Surg 2:387–93.
McGregor IA, Morgan G (1973) Axial and randompattern flaps, Br J Plast Surg 26:202–
13.
Muhlbaeur W, Herndl E, Stock W (1982) The forearm flap , Plast Reconstr Surg 70:336–
44.
Noreldin AA, Fukuta K, Jackson IT (1992) Role of perivenous areolar tissue in the
viability of venous flaps: an experimental study on the inferior epigastric venous flap
of the rat, Br J Plast Surg 45:18–22.
Nylen S, Carlsson B (1980) Time factor, infection frequency and quantitative
microbiology in hand injuries, Scand J Plast Reconstr Surg 14:185–9.
O’Brien BM, Morrison WA, Ishida H, MacLeod AM, Gilbert A (1974) Free flap
transfers with microvascular anastomoses, Br J Plast Surg 27:220–30.
Free flaps 55
Ohmori K, Harii K (1976) Free dorsalis pedis sensory flap to the hand with microneuro-
vascular anastomoses, Plast Reconstr Surg 58:546–54.
Pho RWH (1979) Free vascularised fibular transplant for replacement of the lower radius,
J Bone Joint Surg 61B:362–5.
Robinson DW (1976) Microsurgical transfer of the dorsalis pedis neuro-vascular island
flap, Br J Plast Surg 29:209–13.
Robson MC, Edstron LE, Krizek TJ, Groskin MG (1974) The efficacy of systemic
antibiotics in the treatment of granulating wounds, J Surg Res 16:299–306.
Sanger JR, Matloub HS, Yousif NJ (1990) Sequential connection flaps: a logical
approach to customized mandibular reconstruction. Ann J Surg 160:402–4.
Schenck RR (1978) Rectus femoris muscle and composite skin transplantation by
microneuro-vascular anastomosis for avulsion of forearm muscles, J Hand Surg 3:60–
9.
Shalaby HA, Saad MA (1993) The venous island flap: is it purely venous? Br J Plast
Surg 46:285–7.
Song R, Gao Y, Song Y, Yu Y, Song Y (1982) The forearm flap, Clin Plast Surg 9:21–6.
Soutar DS, Scheker LM, Tanner NSB, McGregor IA (1983) The radial forearm flap: a
versatile method for intra-oral reconstruction, Br J Plast Surg 36:1–8.
Taylor GI, Townsend P (1979) Composite free flap and tendon transfer: an anatomical
study and a clinical technique, Br J Plast Surg 32:170–83.
Thatte RL, Thatte MR (1987) Cephalic venous flap, Br J Plast Surg 40:16–19.
Weiland AJ, Kleinert HE, Kutz JE, Daniel RK (1979) Free vascularised bone in surgery
of upper extremity, J Hand Surg 4:129–44.
Wells MD, Luce EA, Edwards AL, Vasconez HC, Sadove RC, Bouzaglou S (1994)
Sequentially linked free flaps in head and neck reconstruction, Clin Plast Surg 21:59–
67.
Wood MB (1987) Upper extremity reconstruction by vascularised bone transfer: results
and complications, J Hand Surg 12:422–7.
Yang DY, Gu YD (1979) [Thumb reconstruction utilizing second toe transplantation by
microvascular anastomosis: report of 78 cases], Chinese Med J 92:295. (Translation
by Khoo Boo-Chai: Plast Reconstr Surg 1980;65:704.)
Zhong-Jia Y (1987) Microsurgical composite free tissue transfer for extremity trauma,
5
Emergency free flaps for the reconstruction
of open injuries of the upper limb
Maurizio Calcagni and Giorgio Pajardi
Introduction
Currently, debridement of all necrotic and contaminated tissues followed by immediate

soft tissue coverage in order to obtain primary healing is the standard approach to all
open injuries of the extremities. In 1977, Foucher et al introduced for the first time, the
concept of immediate treatment at one time of all injured tissues in complex trauma of
the upper limb. A similar approach to injuries of the lower extremity was documented in
the works of Byrd et al (1981, 1985) and Godina (1986), who demonstrated the
superiority of early closure of complex lesions with free flaps so as to reduce risk of
infection and hospital stay and to improve flap survival rate. The final goal of this
therapeutic approach called ‘Tout en un temps et mobilisation precoce’ (all-in-one stage
and early motion) is early postoperative mobilization of the hand and of the whole upper
extremity (Foucher et al 1977). Delay in treatment will lead to higher risk of infection,
granulation tissue formation and extended fibrosis, reduced flap survival rate, longer
hospital stay, late rehabilitation and eventually poor function.
Similar conclusions were later reported by other authors who demonstrated the
feasibility of immediate free flap closure with free flaps of contaminated open wounds of
the upper limb (Lister and Scheker 1988, Breidenbach 1989). In the 1990s some papers
further supported this concept sharing some common considerations: the need for
appropriate debridement and for immediate (or early) coverage with flaps of all open
wounds with exposed vital structures and/or high risk of infection (Chen et al 1992,
Chick et al 1992, Ninkovic et al 1995a, McCabe and Breidenbach 1999).
Some points of discussion about early closure of open wounds are still controversial:
the most appropriate timing for wound closure; indications for early free flaps; and
possible disadvantages of this kind of surgery.
Timing
The timing of early closure of wounds has been described with different and sometimes
confusing definitions. Lister and Scheker (1988) called the procedure an emergency free
flap all transfers performed within 24 hours of the trauma. Godina (1986) defined early
free flaps as all procedures done within 72 hours. Acute flaps have been defined as those
transferred within 5 days by Byrd et al (1981, 1985). Breidenbach (1989) used the term
emergency free flaps for all flaps used to cover a soft tissue defect within 24 hours of the
injury. Ninkovic et al (1995a,b) proposed the terms primary closure (within 24 hours),
delayed primary closure (within 7 days) and delayed closure with free flaps.
Emergency free flaps for the reconstruction of open injuries of the upper limb 57
In our opinion the nomenclature proposed by Breidenbach (1989) better classifies the
timing of reconstruction of upper extremity open wounds (Table 1).
Relevance of timing has been stressed in many papers but the evidence is
contradictory. Some
Table 1 Definition of timing of reconstruction of open wounds of the upper

extremity according to Breidenbach (1989).
Definition Timing
Emergency closure Within 24 hours of injury
Early closure From 24 hours to 7 days after injury
Delayed primary From 1 week or prior to formation of extensive
closure granulation tissue
Delayed closure Secondary closure of a wound
authors advocate immediate closure with emergency free tissue transfer, others argue that
delayed closure after 5 days can be detrimental, while others state that such a delay does
not affect results. Godina (1986) divided patients who underwent a microsurgical
reconstruction of the extremities into early, delayed and late groups. The early group was
treated within 72 hours of the injury and showed the lowest infection rate and percentage
of flap failure, and bone healing time and hospital stay were markedly reduced as
compared to delayed and late groups.
Lister and Scheker published two papers (Scheker et al 1987, Lister and Scheker
1988) supporting the advantages of immediate reconstruction with emergency free flaps
showing a very low percentage of complications (two flaps lost out of 31). Similar results
were demonstrated in later papers (Chen et al 1992, Chick et al 1992, Ninkovic et al 1995
a,b, Schwabegger et al 1999).
In the last 2 years we have treated all complex injuries of the upper extremity in
emergency, but in the past this was not the case and a delay of 2–3 days was the rule.
Flap survival and infection rate were similar. Hospital stay conversely was longer in
patients treated in the early period compared to those treated in emergency.
Indications
Free flaps are needed when the loss of substance is too large, or too deep, or too complex
to be closed with a local or regional flap, and where a skin graft would be inappropriate
because of poor bed conditions, or because it would endanger function or further
reconstructions.
The first absolute indication is an exposed vital structure. Vital structures are those
that will rapidly undergo desiccation and necrosis if not covered by adequate soft tissue.
The most important among these are the vein grafts reconstructing the arterial circulation
of a limb or its major vessel (Breidenbach 1989, Chen et al 1992). Other vital structures
that, if left exposed will get desiccated and eventually infected are nerves, joints, denuded
bone and tendons (Fig. 1) (McCabe and Breidenbach 1999). These structures can stand a
short period of time of exposure (better when covered with some sort of temporary skin
substitute), but need to be adequately covered as soon as possible to retain useful

function.
High risk of infection, which is one of the most function-threatening factors in open
injuries, is also a major indication. Infection means further loss of previously vital tissue
(and possibly of the flap too) and it reduces functional recovery and eventually can
endanger limb survival. Debridement is the first and most important step in the treatment
of contaminated wounds and the use of free tissue transfer may allow for an increased
freedom in performing a true radical debridement (Ninkovic et al 1995a, McCabe and
Breidenbach 1999) with the possibility of more complex and extended reconstructions.
Two different techniques of debridement are available: serial and radical. When the
serial approach is chosen the patient is taken to the operating room several times over the
first 2–3 days and the tissue is allowed to demarcate itself over time and coverage is
accomplished only at the end of the process. This approach (also called ‘wait and see’) is
problematic when vital structures are exposed, as already discussed, and it is
incompatible with emergency free tissue coverage.
The principle of radical debridement is to make an incision through normal, healthy
tissue to be sure that all non-viable tissue is eliminated, (Ninkovic et al 1995a), all
longitudinal vital structures (vessels, nerves, bones and tendons) if not completely
devitalized are preserved. This tech
Figure 1
(a) Friction avulsion of all soft tissues of the dorsum of the
hand with bone and carpometacarpal joint exposure. (b)
Debridement, joint stabilization and tendon grafting. (c)
An omolateral lateral arm flap is planned. (d) Early result
at 10 days with viable flap and start of rehabilitation.
nique requires excision not only of all clearly non-viable tissue, but also of all tissue that
is at all questionable. This approach may lead to removal of normal tissue, but allows for
safer immediate closure of the wound. In these cases free flaps are often the only mean to
obliterate all dead spaces and achieve complete skin closure.
Ninkovic et al (1995a) proposed a very early second look operation and definitive
coverage (within 24 hours from injury) trying to overcome the risk of misjudgements of
an inexperienced or exhausted team.
In addition, choice of recipient vessels is fundamental in immediate free flap transfer.
The vessels should be well out of the crushed zone and should be checked under high
magnification for intima damage. During debridement the disrupted vessels can be
clamped and, after release of the tourniquet, their health can be easily determined (Chen
et al 1992) without risk of overresection and thus reducing the need for long vein grafts.
Other indications for emergency free flaps are flow-through flaps and salvage flaps.
The first is not a recent concept (Foucher et al 1984, Partecke and Buck-Gramko 1984)
and has several advantages: the need for a separately harvested vascular graft is avoided,
the type of vascular conduit is a better match (artery-to-artery) than vein grafts and the
number of anastomoses is reduced (Brandt et al 1996).
Salvage flaps are harvested from nonreplantable parts in order to preserve stump
length, decrease amputation level (Chen et al 1992) and preserve as much residual
function as possible. In this case timing is not questionable and the flap has to be
transferred in emergency. Relative indications are all the reconstructions with special
features. This is the case of digital or web reconstruction with flaps from the foot (Fig. 2).
In these situations early definitive reconstruction is fundamental for a fast functional
recovery and return to work.
Finally, in some patients, aesthetic concerns can make free flaps preferable in order to
minimize the donor site morbidity. This is also true in special cases like extensive burns
where healthy donor sites are greatly reduced.
Disadvantages
There are some disadvantages of immediate free tissue transfer. Free flap surgery
performed in emergency by inexperienced surgeons and in less than optimal conditions
may lead to a higher rate of complications. There are some steps in the planning of this
type of surgery where experience is crucial: assessment of the general condition of the
patient; assessment of the remaining function of the injured limb; assessment of the
adequacy of wound debridement; and assessment of health of the recipient vessels.
Careful assessment of the systemic condition of the patient should be carried out
before choosing an emergency free tissue transfer. In case of multiple trauma saving the
patient’s life always precedes limb salvage. An often lengthy and complex procedure like
a free flap transfer may not be indicated in patients with associated life-threatening
injuries.
The wound should be inspected and complex reconstruction should be undertaken
only when good remaining function of the limb is expected (Chen et al 1992). It is
unwise, and also disadvantageous for the patients, to perform aggressive surgery on a
limb that will be amputated secondarily (Breidenbach 1989, Chen et al 1990).
Wound debridement is the first and probably most important step in successful
treatment of open injuries of the extremities (Lister and Scheker 1988). Insufficient
debridement may lead to infection and eventually to flap necrosis and/or limb ischaemia
(Breidenbach 1989, Chen et al 1992). In all cases where a clean wound (bacterial count
below 104 in quantitative cultures (Breidenbach 1989, Chen et al 1990) is not obtainable
further debridement should be carried out and free flap reconstruction postponed. It is our
opinion that a delay of 24–48 hours has no adverse effects on success rate and that, in all
cases, when experienced judgement is not available it is better to postpone the
reconstruction in the early period.
Flap choice
There is no fixed rule in choosing a flap. In our department large defects are covered with
latissimus dorsi muscle free flap and split thickness skin grafts. Smaller defects are often
treated with island flaps (mainly the reverse posterior interosseous island flap). When the
lesion is not amenable to closure with a regional flap the free flap is chosen according to
the specific requirements.
Conclusions
The advantages of an emergency free flap reconstruction are salvage of exposed vital
structures, reduction of bacterial colonization and immediate reconstruction of all
damaged structures in the first surgical procedure. Furthermore this approach allows early
rehabilitation, reduces hospital stay and eventually leads to better functional recovery.
In the absence of life-threatening injuries the absolute indication for an emergency
free flap is exposure of a reconstructed vessel and/or of the main artery of the limb. Other
absolute indications are salvage free flaps harvested from nonreplantable amputated parts
and the flowthrough flaps used for limb revascularization.
Figure 2
(a) High voltage injury of the thumb. (b) Debridement of
all non-viable tissues. (c) A cutaneous flap from the pulp
of great toe is planned. (d) Immediate result. (e) Result at 3
months.
The golden period for free tissue transfer is the first 24 hours after injury. In the literature
there is evidence that 3 days and even 5 days are of no detriment to final outcome if
debridement is accurate and bacterial load low. Longer delay is consistently associated
with higher infection rate, flap failure, multiple secondary procedures, longer hospital
stay and eventually poor function.
The disadvantage of emergency free flaps is the need for an experienced surgeon
capable, first of all, of careful assessment of the general condition of the patient and of
the remaining function of the affected limb. Further critical points are the extent of the
debridement and the choice of the receiving vessels.
A definitive closure should be undertaken only when a surgically clean wound is
obtained.
In our opinion there are multiple methods available to close a complex wound of the
extremities and the surgeon should choose the technique that offers the best chance of
success at the lowest risk for the patient. Free flaps do not exclude local or regional ones,
but offer greater flexibility in size, shape and tissue composition without adding donor
site morbidity to the already injured limb.
References
Brandt K, Khouri RK, Upton J (1996) Free flaps as flowthrough vascular conduits for
simultaneous coverage and revascularization of the hand or digit, Plast Reconstr Surg
98:321–7.
Breidenbach WC (1989) Emergency free tissue transfer for reconstruction of acute upper
extremity wounds, Clin Plast Surg 16:505–14.
Byrd S, Cierny GI, Tebbets J (1981) The management of open tibial fractures with
associated soft tissue loss: external pin fixation with early flap coverage, Plast
Byrd H, Spicer T, Cierney GI (1985) Management of open tibial fractures, Plast Reconstr
Surg 76:719–30.
Chen S, Wei FC, Tsai YC, Gau YL (1990) Emergency free flaps to the type IIIC tibial
fracture, Ann Plast Surg 25:223–8.
Chen SH, Wei FO, Chen HC, Chuang CC, Noordhoff MS (1992) Emergency free-flap
transfer for reconstruction of acute complex extremity wounds, Plast Reconstr Surg
89:882–8; discussion 889–90.
Chick RL, Lister GD, Sowder L (1992) Early free-flap coverage of electrical and thermal
burns, Plast Reconstr Surg 89:1013–21.
Foucher G, Merle M, Michon J (1977) Traitement ‘Tout en un Temps’ des traumatismes
complexes de la main avec mobilisation précoce , Ann Chir 31:1059–63.
Foucher G, Van Genechten F, Merle M, Michon J (1984) A compound radial artery
forearm flap in hand surgery: an original modification of the Chinese forearm flap, Br
Godina M (1986) Early microsurgical reconstruction of complex trauma of the upper
extremity, Plast Reconstr Surg 78:285–92.
Lister G, Scheker L (1988) Emergency free flaps to the upper extremity, J Hand Surg
(Am) 13:22–8.
McCabe SJ, Breidenbach WC (1999) The role of emergency free flaps for hand trauma,
Hand Clin 15:275–88, viii–ix.
Ninkovic M, Deetjen H, Ohler K, Anderl H (1995a) Emergency free tissue transfer for
severe upper extremity injuries, J Hand Surg (Br) 20:53–8.
Ninkovic M, Hussl H, Hefel L, Anderl H (1995b) [Timing of management of severe
injuries of the upper extremity by free flap-plasty], Handchir Mikrochir Plast Chir
27:297–306.
Partecke BD, Buck-Gramko D (1984) Free forearm flap for reconstruction of soft tissue
defects concurrent with improved peripheral circulation, J Reconstr Microsurg 1:1–6.
Scheker LR, Kleinert HE, Hanel DP (1987) Lateral arm composite tissue transfer to
ipsilateral hand defects, J Hand Surg (Am) 12:665–72.
Schwabegger AH, Anderl H, Hussl H, Ninkovic MM (1999) [Complex hand injuries.
Importance of primary repair with free flaps], Unfallchirurg 102:292–7.
Bone reconstruction
6
Bone auto- and allografts in post-traumatic
reconstruction of the upper limb
Olivier Barbier and Jean-Jacques Rombouts
In cases of severe lesions involving multiple tissues, the basic principles of early
debridement, stabilization, cover with vascularized soft tissue and osseous reconstruction
remain central to management. The treatment of post-traumatic skeletal conditions such
as delayed unions, nonunions, malunions and other problems of bone loss is challenging.
In many cases, adjunctive measures such as bone grafting are required to stimulate bone
healing and fill bone defects.
The receiver site
In the case of a non-vascularized bone graft, the process of incorporation is primarily the
function of the recipient bed and depends on close contact with viable tissue (Nather et al
1990).
A considerable amount of autogenous cancellous bone graft, with an adequate soft
tissue coverage like a healthy muscle (Lukash et al 1974), can accomplish the osseous
reconstruction in large diaphyseal defects (Christian et al 1989). Muscle also offers better
control of subflap bacterial levels and may improve delivery of antibiotics to the bone
(Mathes 1982). In open fractures, because of the risk of infection, bone grafts are rarely
applied initially with the exception of type I and type II intraarticular fractures when bone
is necessary to fill defects for obtaining reduction and stability. In type III open fractures,
bone grafting is generally delayed until after the soft tissues have recovered from the
acute trauma. This is generally about 6 weeks after injury. Bone grafting done too early
might allow the graft to become infected, whereas too long a delay would result in greater
atrophy and fibrosis of the soft tissues and would jeopardize the other reconstructive
procedures (Grace and Eversmann 1980).
In general, the absence of any clinical or radiographic evidence of progression of
fracture healing for 2–3 months after the expected time period for healing constitutes a
non-union (Chapman 2001). Devascularization and excessive motion at the fracture site
are the most common causes of non-union. Oligotrophic nonunions and all of the
avascular non-unions (Weber and Cech 1976) require bone grafting. In the case of
infected non-union, the infection has first to be controlled. All necrotic and infected bone
as well as implants are removed. The bone is stabilized with external fixation. After
debridement, antibiotherapy is administered according to the cultures. Local or free flaps
may be necessary to revascularize the site of non-union. If the wound has been clean for
about 6 weeks, a bone graft is applied.
Bone auto-and allografts in post-traumatic reconstruction of the upper limb 65
Bone auto- and allografts
Biological properties
Autograft
An autologous bone graft allows healing and remodelling to proceed through physiologic
mechanisms. The initial process is always vascular invasion. The graft remodels by
osteoclastic degradation and osteoblastic new bone formation. This resorption and
apposition was called as ‘creeping substitution’ in the English literature. It differs from
the process of incorporation of a bone graft with microvascular anastomosis (Dell et al
1985). The autograft contains the mineral, protein and cellular elements of normal bone
tissue, arranged in a physiologic matrix. The matrix provides a scaffold for new bone
formation and has osteoconductive properties. The osteoinductive properties of the graft
influence immigrant cells possessing the pluripotential characteristics of primitive
mesenchyme to undergo differentiation into osteoblasts (Lacroix 1947). Some surviving
bone cells (Gray and Elves 1979), along with the structural and regulatory matrix proteins
(Mundy 1996), make autograft osteogenic, or having the intrinsic potential to form new
bone at non-skeletal sites. Cancellous bone graft has the greatest osteogenic potential.
Allograft
Allogeneic bone, with variable biologic properties, is available in many preparations:
cancellous or corticocancellous frozen or freeze-dried pieces, osteochondral frozen grafts
and demineralized bone matrix.
Large frozen allografts are essentially osteoconductive Union between the allograft
and the host takes place at the cortical junctions by external callus advancing from the
host. Internal repair is confined to the surface and involves only 20% of the graft by 5
years (Enneking and Mindell 1991). Experimental data suggest that the revitalization of
the graft increases by perforating the cortical bone which augments the interface between
living soft tissues of the host and the allografted bone (Delloye et al 2002). The majority
of the immune stimulation of a bone allograft is derived from cell surface glycoprotein
antigens controlled by the major histocompatibility complex. The antigen–antibody
response to allografts varies considerably in reported series (Stevenson et al 1996). Bone
graft immunogenicity is influenced by the manipulation for the purpose of preservation.
Frozen bone is less immunogenic than fresh bone and freeze-dried bone is even less
reactive (Friedlaender et al 1976). The inclusion of cryoprotectant, while necessary to
maintain the integrity of chondrocytes, also has been shown to protect cells in general
from the effects of freezing, including the surface antigens (Mazur 1984). In intact
cartilage frozen with a cryopreservative (dimethylsulphoxide), approximately 10–30% of
chondrocytes will survive (Tomford et al 1986). But there is a severe loss and lack of
proteoglycans several months after transplantation (Tomford et al 1984). Analysis of the
articular cartilage of retrieved human allografts revealed no evidence of chondrocytes
having survived (Enneking and Mindell 1991).
A freeze-dried tissue has no cell survival and does not elicit a humoral immune
response. This graft has only osteoconductive properties.
Demineralized bone matrix (Urist et al 1967) shows osteoinductive activity

attributable to proteins and various growth factors present in the extracellular matrix and
made available to the host environment by the demineralization process.
Structural properties
Successful bone grafts must be well matched to the structural demands of a particular
clinical situation. Bone consists of hydroxyapatite, a calcium phosphate salt, deposited on
a matrix of type I collagen. The mineral component confers rigidity. The organic matrix
provides a scaffolding for bone formation and contributes tensile strength.
Autograft
The biomechanical strength of the bone transplant can be correlated with the process of
its repair. Cancellous transplants are first strengthened by the addition of new bone.
Thereafter, when the old, necrotic bone is removed, the mechanical strength of
transplanted areas tends to return to normal. Conversely, osteoclastic resorption of the
bone within the haversian system takes place before apposition in the repair of
transplanted cortical bone (Enneking et al 1975). Clinical experience permits to predict
that a human autogenous cortical transplant will develop its maximal weakness from 12
weeks to at least 48 weeks and then return to its original strength by 2 years (Springfield
1987). The rate of creeping substitution is dependent on the speed of revascularization. It
takes years for autogenous cortical grafts to hypertrophy in relation to the presence of
mechanical stress (Wilson 1972). Although a cancellous graft does not provide
immediate structural support, it incorporates quickly and ultimately achieves strength
equivalent to that of a cortical graft after 6–12 months (Gazdag et al 1995).
Allograft
The ability of the graft to withstand the loads to which it is subjected is largely
determined by the original properties of bone at the time of donation. Bone tissues tend to
be strongest between 20 and 40 years of age.
Little change in the bending, torsional or compressive strength has been noted after
freezing (Pelker et al 1984).
Decalcified allografts repair at a faster rate than those that are only frozen but,
initially, they are mechanically weaker (Oikarinen 1982).
Freeze-drying and gamma irradiation, commonly used for preservation and
sterilization in bone banking, add their negative effects to the mechanical resistance
(Cornu et al 2000).
Choice of bone graft

The first step in matching the graft to the clinical problem is to examine whether the
problem is a lack of osteoinduction and/or osteogenesis or one of structural bone loss
requiring a loadbearing graft.
For segmental defects which require immediate structural support, autologous cortical
bone grafts are good choices (Grace and Eversmann 1980). Reconstruction of traumatic
defects up to 20 cm with a fibular cortical autograft is possible at the level of the radius
(Miller and Phalen 1947).
The advantages of autologous bone grafts are their excellent success rate, low risk of
transmitting disease and histocompatibility. However, there is a limited quantity of
autologous bone graft and the potential for donor site morbidity. Cortical allografts are
best reserved for use in areas with an excellent vascular supply. Bone transport may also
be an option in large defects (Green 1994).
In small diaphyseal defects (< 6 cm), autologous cancellous bone used with stable
internal fixation is adequate (Nicoll 1956). Demineralized bone matrix is useful for filling
stable, well-contained bone defects. A percutaneous procedure utilizing demineralized
bone matrix and autologous bone marrow could be considered (Tiedeman et al 1991)
although there is no definitive evidence of clinical success.
Well-contained, stable, metaphyseal defects with a good vascular supply are well
suited for osteoconductive bone grafts like frozen or freezedried (Fig. 1)
corticocancellous allografts that can resist compressive forces.
If a non-union is present and a stimulus for new bone formation is needed, an
autologous cancellous graft is ideal.
Severe soft tissue injuries frequently accompany the bony trauma, and many of the
wounds have been previously infected. Morcellized bone grafts appear to incorporate
faster than large segmental grafts (Coutelier et al 1984) and bacteria are much less likely
to survive in these small, rapidly revascularized pieces.
How to obtain a bone graft?
Autograft
The iliac crest is the most common donor site because of easy access, relatively low
morbidity, and availability of large quantities of both cortical and cancellous bone.
Harvesting from the anterior iliac crest is usually more convenient because the patient
is typically in a supine position for most operations involving the extremities. An incision
lateral to the iliac wing is made 2 cm dorsal to the anterior superior iliac spine in order to
avoid injuring the lateral femoral cutaneous nerve and to avoid predisposing the iliac
spine to an avulsion fracture. The tubercle, being the widest part of the crest, contains the
largest amount of corticocancellous bone. The apex of the crest is incised longitudinally,
between the abdominal and gluteus muscles. The iliacus is dissected from the inner
Figure 1
Freeze-dried allograft of an unstable epihyseal fracture of
the distal radius in a 19-year-old boy. (a,b) Epiphyseal
fracture with dorsal displacement. (c) Secondary dorsal
displacement under a cast due to posterior comminution at
2 weeks after initial reduction. (d) New reduction
stabilized by a freeze-dried corticocancellous allograft
(high density in the epiphysis on the radiograph), two pins
and a cast. (e,f) At 3 months—fracture consolidation with
integration of the allograft.
Figure 2
Abdominal hernia through a defect in the iliac wing after
bone removal for a graft. (a) The computerized
tomography scan shows the left iliac hernia. (b) AP
(anteroposterior) radiograph of the left iliac wing.
wall of the ilium. To avoid injuring the abductor muscles only harvest the inner table.
Thereafter, the abdominal muscles are meticulously closed to the abductor musculature to
minimize the risk of hernia (Fig. 2). A bicortical graft can be harvested from just below
the iliac tubercle, including both outer and inner cortical tables. The continuity of the
crest is preserved. A small graft can be harvested by using a trephine forceps (Saleh
1991).
To harvest the posterior bone grafts, an almost vertical incision is made slightly lateral
to the posterior iliac spine. A transverse incision is dangerous for the cluneal nerves
(Finkemeier 2002), more likely to result in dehiscence and can be painful if it lies along
the belt line. The cluneal nerves which cross the iliac crest beyond approximately 8 cm
anteriorly from the posterior midline provide sensation to the region of the posterior iliac
crest and the cephalad portion of the buttock. The patient is usually prone but can also be
placed in a lateral position. The gluteal fascia is incised along the crest. The gluteus can
be elevated off the outer wall of the ilium down to the level of the sciatic notch. Injury to
the superior gluteal nerve and vessels and penetration of the sacroiliac joint are avoided.
Bleeding is controlled with a collagen product placed on the donor site. The use of bone
wax should be discontinued as it may elicit a foreign body reaction (Verborgt et al 2000).
Depending on the quantity of the procured bone, a bone allograft can be implanted to
reshape the defect. The use of an anaesthetic regimen at the donor site could overcome
the problem of pain at the wound site (Puri et al 2000).
Other potential areas for harvesting cancellous bone include metaphyseal regions of
the skeleton, such as Gerdy’s tubercle, the proximal tibial and the greater trochanter
(Finkemeier 2002). For upper extremity procedures obtaining a bone graft from the
olecranon or distal radius allows the surgical procedure to be limited to the involved
extremity. The primary disadvantage of local upper extremity graft is the limited amount
of bone available (Bruno et al 2001). The distal radius seems structurally inferior and has
lower bone turnover compared with the iliac crest. However, the difference is of minimal
clinical significance when the bone is used as graft material (Biddulph 1999). The radius
is approached between the first and second dorsal compartments. A section of cortex is
outlined with multiple drill holes. Cancellous bone is resected with a curette. The ulna
below the elbow is approached through an incision to either side of the donor site along
the dorsal subcutaneous ulnar ridge. The graft is taken below the olecranon, to avoid
weakness over the elbow joint, and well distal to the epiphysis (McCrath and Watson
1981).
The fibula is the most common bone used for long cortical autogenous grafts. The
fibula is exposed through a lateral approach, between the soleus and peroneal muscles.
The periosteum is stripped with an elevator. Patients younger than 9 years of age can
develop a valgus ankle if the fibula is removed and does not regenerate. It is
recommended leaving the distal 8–10 cm of fibula to avoid changes at the ankle.
Removal of the fibular head will not lead to knee instability by suturing the biceps tendon
and fibular collateral ligament to the soft tissue attached to the tibia. For maximum
osteocyte survival, bone grafts should be kept in chilled blood or a sponge moistened
with chilled saline and not exposed to air (Berggren et al 1981).
Autologous red bone marrow, usually obtained by aspiration in adults from the axial
skeleton, contains a small but significant number of pluripotential mesenchymal stem
cells and inductive factors that have been used to treat non-unions (Tiedeman et al 1991).
Allograft
Human bones available from the bank attached to our department of orthopaedic surgery
are essentially in frozen and freeze-dried forms. Allografts come from living donors
having hip replacements or from cadavers. Selection of a donor presenting minimal risk
of transmitting disease to a recipient is one of the major responsibilities of the tissue bank
(Delloye 2000). Bone allografts have transmitted hepatitis B and C, HIV-1 and
tuberculosis (Tomford 1995).
Donors are excluded if they present a suspicion of central nervous disease, a risk for
HIV or hepatitis B or C. They are also excluded in cases of connective tissue disease or
malignant disease. Several serological tests are performed on the donor (hepatitis B and
C, HIV, syphilis). Risk is associated with a seronegative window during which a virus-
contaminated donor can transmit the virus while the serum still remains negative for
antibodies. The risk of a ‘window donation’ is one per 166 000 for HIV and one per 6100
for hepatitis C (Lelie et al 1996). The risk of a window donation can be lowered by
additional safety measures like the amplification of the viral genome that has been
intercalated into the patient’s DNA (polymerase chain reaction). For a living donor,
serological tests are repeated. Rhesus matching is necessary for a Rhesus negative female
patient with child-bearing potential because a Rhesus positive allograft is able to sensitize
a Rhesus negative recipient (Johnson et al 1985). HLA (human leucocyte antigen)
histocompatibility group matching does not appear necessary to achieve a successful
allograft (Stevenson et al 1996). The bone is explanted in sterile conditions. A sample,
representative of the tissue, is cultured. Then the bone is immersed in a solution
containing rifampicin. Deep-freezing (–80°C) is the most convenient and widespread
method of tissue preservation. Water contained in the tissue is converted into ice and is
therefore no longer available for further chemical reaction.
The process of freeze-drying removes water from the tissue by chemical agents such
as acetone or ether. These agents are able to inactivate coated viruses such as HIV and
hepatitis B and C (Anastasescou et al 1998). However, penetration into the core of the
tissue might take longer depending on the nature of the tissue, the thickness of the sample
and the quantity of fat bone marrow. For prion disease, contamination through a
musculoskeletal tissue has not yet been demonstrated. However, an effective treatment
with sodium hydroxide or sodium hypochlorite is applied (WHO 1992). Dehydration is
completed when the tissue has less than 5% residual humidity. Lyophylization is then
performed by sublimation of ice which requires freezing and vacuum conditions.
Numerous different demineralized bone allograft preparations are now available
(Finkemeier 2002). The decalcification process with HCl appears to inactivate and
eliminate HIV (Prewett et al 1992).
Applications of bone grafts
All the grafts must be appropriately protected during incorporation by adequate internal
or external fixation and/or external bracing.
Scapular girdle
In a comminuted fracture, the glenoid rim can be reconstructed with a block of iliac crest
(Goss 1992).
Treated non-operatively, the vast majority of middle-third clavicle fractures, which

account for approximately 80% of all clavicle fractures, heal uneventfully. Malunion and
non-union are rarely functional or clinically significant problems. Indications for surgical
treatment of clavicular nonunion are: pain attributable to the non-union; shoulder girdle
dysfunction; and neurovascular compromise (Barbier et al 1997). Plate fixation with the
use of autogenous bone grafting is an excellent method of treatment for these injuries
(Mullaji and Jupiter 1994). Plates fit best on the superior clavicle. At the clavicle, like for
other inter calated bone grafts, it is recommended (Davey and Simonis 2002) to chamfer
the cut ends of the receiver bone and the bone graft in order to increase the area of
contact and to allow the graft to be wedged securely in place. The cortical surface of the
graft is positioned opposite the plate to allow firm compression without crushing (Fig. 3).
Figure 3
Peroperative view of an intercalated bone graft in a long
bone (clavicle). The cut ends of the graft and the receiver
bone are chamfered (arrows). The plate is on the superior
side of the clavicle, opposite to the cortical surface of the
graft.
Shoulder
There are few surgical options for reconstruction of an osteoarticular loss at the shoulder
level. Vascularized or non-vascularized fibula transfer has been used, but this does not
offer an anatomical joint surface. In the replacement of the joint, fixation of soft tissue
remains a major concern with potential subsequent instability and restricted motion. An
osteoarticular allograft resolves the problem of soft tissue fixation and consequently of
joint stabilization. However, no patient regains normal abduction despite an anatomical
reconstruction (Delloye et al 1991). The necrotic cartilage of the allograft can maintain
good architecture for several years. Two clinical circumstances appeared to be associated
with this phenomenon: a good anatomical fit of the graft and satisfactory stability of the
joint that had been engendered by a good soft tissue repair (Enneking and Mindell 1991).
Another interesting option is a combination of a structural allograft and a joint prosthesis.
Arm
Unlike the lower limb, some shortening and/or rotation is tolerated by the arm as long as
function of the hand and the ability to position the hand in space is maintained.
An autogenous reconstruction of the humerus using two fibulae is advisable
(Springfield 1987).
The use of a locked nail and cementing the inner part of a diaphyseal allograft are
some means to prevent mechanical failure. The observation of retrieved human allografts
shows that where bone cement had been used to fix a prosthetic stem or an
intramedullary rod to the allograft, there was no evidence of resorption of bone or
loosening of the device (Enneking and Mindell 1991).
A combination of auto- and allografts is also advisable. Half of an allograft shaft is
used with morcellized autogeneic bone packed around it. This approach has two
advantages: it maximizes the morcellized graft material, and it decreases the volume of
cortical bone that might distend the already shrunken surrounding soft tissue (Chapman
and Rodrigo 2001).
Non-union seems best treated by rigid internal fixation and bone grafting (Foster et al
1985) (Fig. 4). Union rates for non-unions treated with intramedullary fixation and plates
are nearly equivalent (Wu and Shih 1992). At the proximal third, a tension band can fix
the rotator cuff and proximal fragment to the remainder of the shaft
Figure 4
Autogenous bone graft and nail fixation of delayed union
in an unstable humerus. (a) Radiograph of Gustilo IIIC
open fractures of the arm and the forearm. (b) Absence of
bone consolidation at 3 months after a forearm amputation
and unstable humeral fixation as initial treatment. (c)
Immediate postoperative radiograph of stable fixation with
a locked nail. Autogenous iliac bone graft was placed at
the fracture sites (arrows). (d) Consolidation of the
humerus at 1 year.
(Healy et al 1990). All fibrous tissue is removed from between the bone ends. The
medullary canals are open. The cortex is petalled with a small osteotome for a distance at
least equal to the diameter of the cortex at that point on the proximal and distal fragment.
The aim is to augment the surface of living bone and hence its osteogenic capacity, by
creating several chips of cortical bone that remain vascularized through their periosteum
and soft tissues (Judet et al 1992). A layer of autograft is applied along this exposed
surface. When bone stock is a major problem, use of a split autologous fibula or an
allograft to provide a backup to the plate on the opposite cortex for screw fixation can be
useful.
Symptoms from lateral condylar non-union are most often attributable to tardy ulnar
nerve palsy, cubitus valgus deformity or both. Osteosynthesis with iliac crest bone
grafting eventually associated with anterior transposition of the ulnar nerve and a
corrective osteotomy can lead to a pain-free elbow (Inoue and Tamura 1993).
Elbow
In complex fractures involving the trochlea and capitulum, their reconstruction is the
most important step in internal fixation. If there is a defect after reconstruction, it must be
filled with autologous cancellous bone (Helfet and Schmeling 1993). The most common
defects are caused by comminution in the metaphyseal portion of the olecranon fossa,
fragmentation of the supracondylar ridge or loss of the midsubstance of the trochlea. The
superior margin of the iliac crest provides the ideal graft for replacing these deficiencies.
The general categories of treatment for intraarticular and extraarticular non-unions of
the distal humerus are osteosynthesis, total elbow arthroplasty and allograft replacement
(Gallay and McKee 2000). Decortication, autogenous iliac crest bone grafting, and
internal fixation leads to union in more than 90% of cases. However, unless the soft
tissue trauma associated with this injury is considered, a successful result cannot be
achieved (McKee et al 1994).
For olecranon fracture and non-union, depending on the size of the proximal fragment,
whether the articular cartilage is preserved and the quality of the bone, the treatment is
fragment excision, prosthesis or osteosynthesis (Papagelopoulos and Morrey 1994). If
there is segmental comminution in the fracture, tension band wiring is contraindicated
because it will narrow the fossa of the olecranon and produce an incongruous joint. These
require an intercalary bone graft and plate fixation.
The use of joint allografts remains a salvage procedure for massive bone loss of the
elbow joint. Since the allograft is avascular and bulky, adequate skin must be present to
allow wound closure without tension. The results are generally poor with a high
complication rate (70%) including infection, instability and graft resorption—
necessitating removal of the graft in 25% of the cases (Dean et al 1997). Although useful
function can be obtained at an early stage (Urbaniak and Aitken 1987), the complications
indicate that this option for treatment should at present remain experimental. We now
consider that in patients with deficient bone stock, the allografts re-establish bone mass to
permit a potential arthrodesis or prosthetic arthroplasty. Before being implanted, the
allograft is thawed at 40 °C for at least 30 minutes in preheated saline containing
antibiotics. Autografting with cancellous bone procured from the iliac crest is performed
at the junction. Callus develops slowly with union achieved at around 6 months to 1 year
(Fig. 5) (Delloye et al 1991).
In fracture of the radial head, periosteal connections between the fragments should be
preserved. Depressed areas must be reduced and the resultant defects filled with
cancellous bone graft. It can be taken from the nearby epicondyle. If the reconstruction of
the radial head is definitively not adequate, resection of the head or prosthetic
replacement is considered (Ring and Jupiter 1998). Frozen bone allografts have been
used to replace the proximal radius (Delloye et al 1991, Szabo et al 1997). Our longterm
experience with allografts in this situation revealed a high rate of complications.
Forearm
In case of severe fracture of bones of the forearm, the osteosynthesis can be improved
biologically with an additional autologous cancellous bone graft. The graft should be
placed away from the interosseous border to avoid formation of radio-ulnar bridging
callus (Vince and Miller 1987). However, in two studies on comminutive forearm
fractures treated with plates with or without bone graft, the union rate was 98%
(Chapman et al 1989, Wright et al 1997). Most areas of bone loss in the forearm can be
managed with standard bone grafting techniques (Miller and Phalen 1947, Nicoll 1956,
Grace and Eversmann 1980). The host tissues into which the transplant is made must
have a good blood supply, since osteogenesis can occur only if the graft has intimate
contact with an active circulation. All sclerotic bone ends must be removed. Procedures
used in the reconstruction of segmental defects of both bones of the forearm should,
whenever possible, preserve forearm pronation and supination. Most reports of such
reconstructions, however, describe the creation of a single-bone forearm by radio-ulnar
fusion. Attempts to bridge large defects are fraught with problems of delayed or non-
union of the graft–host junction, as well as stress fractures and resorption of the graft;
these may explain
Figure 5
Bone allograft and joint prosthesis with flap coverage in
the treatment of a largely open fracture of the elbow with
loss of the joint. (a) Gustilo IIIB open fracture of the elbow
with large soft tissue defect in front of an open joint. (b)
AP radiograph of the elbow showing loss of distal humerus
and olecranon. (c) AP radiograph of the elbow during the
initial phase of treatment with an external fixator as
stabilizer and cement with antibiotics in the joint as spacer.
(d) AP radiograph at 4 years. In a second phase, at 5 weeks

after the injury, a prosthesis had been cemented through an
allograft of the distal part of the humerus. A callus formed
at the junction between the humerus and the allograft
(arrow). (e) The elbow had been covered in the initial
phase with a pedicled fasciocutaneous radial forearm flap.
the infrequency with which these procedures have been carried out successfully (Haddad
and Drez 1974) and reported. In cases of massive bone loss, infections or recalcitrant
non-union, vascularized bone grafts could be more suitable (Kumar et al 1988).
Wrist
Several investigators have shown improved anatomical and functional outcomes with the
use of autologous bone graft to reconstruct the radial metaphysis (Fernandez and Jupiter
1996).
Autologous bone graft can be used to fill depressed articular surfaces, in association
with internal fixation (Axelrod and McMurtry 1990). Another surgical tactic is based on
external fixation in conjunction with placement of autogenous cancellous bone in the
metaphyseal defect that is always present following reduction of the comminuted
unstable fractures (Leung et al 1990). However, bone graft substitutes or allografts may
be interesting in these cases to avoid donor site morbidity.
Union with deformity continues to be the most common complication following
fracture of the distal end of the radius. The most commonly observed cause of an
extraarticular malunion is secondary displacement of the initial fracture reduction due to
deficient cancellous bone in the metaphysis (McQueen and Caspers 1988). If there is no
marked osteoporosis and advanced carpal lesions, malunion is treated by osteotomy,
distraction, bone graft and plate stabilization.
Fractures of the distal radius that demonstrate either delayed healing or the
development of an atrophic or synovial non-union can be treated with surgical
realignment, stable internal fixation and autogenous iliac crest bone grafting (Fernandez
et al 2001).
In case of severe bone loss, an autogenous transplantation of the proximal fibula or an
osteochondral allograft could maintain some flexion–extension of the wrist and pro-
supination. This has been demonstrated in tumoral reconstruction (Noellert and Louis
1985, Delloye et al 1991). Arthrodesis of the wrist using bone graft seems a more
predictable solution (Freeland et al 2000).
Hand
Large crush injuries or wounds, can cause segmental defects of several metacarpals. In
many cases, autogenous (Bruner 1957) or allogenous (Smith and Brushart 1985) bone
grafts can be used to reconstruct these deficits. Allogeneic bone satisfies the requirements
for reconstruction when there is a need for osteochondral grafts, strong cortical grafts to
allow secure fixation and early motion, and small tubular grafts that meet the demands of
minimizing bulk in the hand.
Complications and limitations of bone grafts
The graft
Auto- and allografts have particular advantages and disadvantages. Compared with
autografts, allografts have less osteogenic potential, variable quality and theoretical
possibility of disease transmission. Bone allograft can fail under repetitive constraint; this
is referred to as fatigue failure. Until the transplanted grafts become vascularized, they do
not have the potential to repair subfailure damage. Thereafter, fracture healing can occur
because of a new host bone and periosteum encompassing the allograft. Moreover,
infection, non-union, cartilage deterioration and bone resorption are serious
complications. To limit allograft infection, the most important factor is the presence of
healthy skin and subcutaneous tissue. Osteochondral allografts preserved by current
techniques are thought to be low in immunogenicity. However, important radiographic
changes are noted on radiographic follow-up evaluations (Urbaniak and Aitken 1987).
This may also be a result of decreased cartilage viability, incongruity (Highgenboten et al
1989) and lack of joint innervation (O’Connor et al 1985). The analysis of retrieved
allografts confirms that cartilage erosions depend on the congruity of the joint (Enneking
and Mindell 1991).
An epiphyseal autograft without microvascular anastomosis has no potential for
growth in a child (Brown et al 1983).
The donor site

At the iliac crest, complications seem 10 times more frequent after anterior harvesting
(25%) than after posterior harvesting (Ahlmann et al 2002). Amongst the complications
associated with the anterior bone graft donor sites are haematoma, numbness over the
distribution of cutaneous nerves (Wechel and Halsal 1977, Smith et al 1984), vascular
injuries (Lim et al 1996, Neo et al 2000), fracture of the iliac wing, visceral and ureteral
injuries (Escalas and DeWald 1977), and infection and pelvic instability (Coventry and
Tapper 1972). A 10% rate of difficulty ambulating 3 months postoperatively is reported
in patients with grafts obtained from the lateral cortex of the iliac crest (Keller and
Triplett 1987). Herniation of the abdominal contents through the wing of the ilium
following the removal of bone from that site for grafting is a relatively rare complication
(Cowley and Anderson 1983). The most common symptoms attributable to the donor site
are pain and sensory disturbances. Variation in the position of the lateral femoral
cutaneous nerve is a contributing factor associated with injury of that nerve (Murata et al
2000).
In children, splitting of the iliac crest can lead to premature growth arret of the ilium,
usually with only minor cosmetic prejudice (Rossillon et al 1999).
Tenderness at the distal dorsal radius donor site has been reported in one of 78 patients
(McCrath and Watson 1981). There are also isolated reports of pathologic fracture
following olecranon and distal radius harvest (Mirly et al 1995).
Conclusions and future directions
Advances made in the techniques of soft tissue treatment, modern methods of stable
fixation, bone reconstitution by the way of grafts and early postoperative rehabilitation
have largely improved the surgeon’s ability to treat the complex problems of severe
traumatic skeletal lesions. New biological methods are now being investigated to
accelerate and augment skeletal reconstitution.
Undifferentiated stem cells are characterized by the ability to differentiate along
various cell lines (Connolly et al 1989). They replace cells that are lost by senescence or
injury. These cells are procured from the bone marrow, isolated and cultured, so that they
will grow with an osteoblastic phenotype. They could be used alone or in association
with a structural graft (Delloye 2001).
The existence of osteo-inductive proteins was demonstrated many decades ago
(Lacroix 1945). Growth factors are proteins that induce stem cells to proliferate or to
differentiate into osteoblast-like cells. Three recombinant osteogenic proteins have been
particularly studied: OP-1; BMP-2; and BMP-4. Research and clinical trials on these
inductive factors are being performed (Friedlaender et al 2001).
References
Ahlmann E, Patzakis M, Roidis N, Shepherd L, Holtom P (2002) Comparison of anterior

and posterior iliac crest bone grafts in terms of harvest-site morbidity and functional
outcomes, J Bone Joint Surg 84A:716–20.
Anastasescou M, Cornu O, Banse X et al (1998) Ethanol treatment of tendon allografts: a
potential HIV inactivating procedure, Int Orthop 22:252–4.
Axelrod TS, McMurtry RY (1990) Open reduction and internal fixation of comminuted,
intra-articular fractures of the distal radius, J Hand Surg 15A:1–11.
Barbier O, Malghem J, Delaere O et al (1997) Injury to the brachial plexus by a fragment
of bone after fracture of the clavicle, J Bone Joint Surg 79B:534–6.
Berggren A, Weiland AJ, Ostrup LT, Dorfman H (1981) The effects of storage media and
perfusion on osteoblast and osteocyte survival in free composite bone grafts, J
Microsurg 2:273–82.
Biddulph SL (1999) Bone donor site: iliac crest or distal radius, J Hand Surg 24B:645–6.
Brown K, Marie P, Lyszakowki T, Daniel R, Cruess R (1983) Epiphysial growth after
free fibular transfer with and without microvascular anastomosis. Experimental study
in the dog, J Bone Joint Surg 65B:493–501.
Bruner JM (1957) Use of single iliac bone graft to replace multiple metacarpal loss in
dorsal injuries of the hand, J Bone Joint Surg 39A:43–52.
Bruno RJ, Cohen MS, Berzins A, Summer DR (2001) Bone graft harvesting from the
distal radius, olecranon, and iliac crest: a quantitative analysis, J Hand Surg 26A:135–
41.
Chapman MW (2001) Principles of treatment of nonunions and malunions. In: Chapman

M, ed. Chapman’s Orthopaedic Surgery, 3rd edn. Lippincott Williams & Wilkins:
Philadelphia, 847–85.
Chapman MW, Rodrigo JJ (2001) Bone grafting, bone graft substitutes, and growth
factors. In: Chapman M, ed. Chapman’s Orthopaedic Surgery, 3rd edn. Lippincott
Williams & Wilkins: Philadelphia, 181–215.
Chapman MW, Gordon JE, Zissimos AG (1989) Compression plate fixation of acute
fractures of the diaphysis of the radius and ulna, J Bone Joint Surg 71A:159–69.
Christian EP, Bosse MJ, Robb G (1989) Reconstruction of large diaphyseal defects,
without free fibular transfer, in grade-IIIB tibial fractures, J Bone Joint Surg 71A:994–
1004.
Connolly J, Guse R, Lippiello L, Dehne R (1989) Development of an osteogenic bone-
marrow preparation, J Bone Joint Surg 71A:684–91.
Cornu O, Banse X, Docquier PL, Luyckx S, Delloye C (2000) Effect of freeze-drying and
gamma irradiation on the mechanical properties of human cancellous bone, J Orthop
Res 18:426–31.
Coutelier L, Delloye C, De Nayer P, Vincent A (1984) Aspects microradiographiques des
allogreffes osseuses massives chez l’homme, Rev Chir Orthop 70:581–8.
Coventry MB, Tapper EM (1972) Pelvic instability: a consequence of removing iliac
bone grafting, J Bone Joint Surg 54A:83–101.
Cowley SP, Anderson LD (1983) Hernias through donor sites for iliac-bone grafts, J
Bone Joint Surg 65A:1023–5.
Davey PA, Simonis RB (2002) Modification of the Nicoll bone-grafting technique for
nonunion of the radius and/or ulna, J Bone Joint Surg 84B:30–3.
Dean GS, Holliger IV EH, Urbaniak JR (1997) Elbow allograft for reconstruction of the
elbow with massive bone loss. Long term results, Clin Orthop 341:12–22.
Dell PC, Burchardt H, Glowczewskie FP Jr (1985) A roentgenographic, biomechanical,
and histological evaluation of vascularized and non-vascularized segmental fibular
canine autografts, J Bone Joint Surg 67A:107–12.
Delloye C (2000) Bone banking in orthopaedic surgery. In: Dupore J, ed. Surgical
Techniques in Orthopaedics and Traumatology. Editions Scientifiques et Médicales
Elsevier SAS: Paris.
Delloye C (2001) Bone grafts using tissue engineering (in French), Bull Mem Acad R
Med Belg 156:418–26.
Delloye C, De Nayer P, Vincent A (1991) Osteochondral allografts in arm and forearm
surgery, Acta Orthop Belg 57(Suppl II):75–83.
Delloye C, Simon P, Nyssen-Behets C, Banse X, Bresler F et al (2002) Perforations of
cortical bone allografts improve their incorporation, Clin Orthop 396:240–7.
Enneking WF, Mindell ER (1991) Observations on massive retrieved human allografts, J
Enneking WF, Burchardt H, Puhl JJ, Piotrowski G (1975) Physical and biological aspects
of repair in dog cortical bone transplants, J Bone Joint Surg 57A:237–52.
Escalas F, DeWald RL (1977) Combined traumatic arteriovenous fistula and ureteral
injury: a complication of iliac bone grafting, J Bone Joint Surg 59A:270–1.
Fernandez DL, Jupiter JB (1996) Fractures of the Distal Radius. A Practical Approach to
Management. SpringerVerlag: New York.
Fernandez DL, Ring D, Jupiter JB (2001) Surgical management of delayed union and
nonunion of distal radius fractures, J Hand Surg 26A:201–9.
Finkemeier CG (2002) Current concepts review. Bonegrafting and bone-graft substitutes,
J Bone Joint Surg 84A:454–64.
Foster RJ, Dixon GL, Bach AW, Appleyard RW, Green TM (1985) Internal fixation of
fractures and non-unions of the humeral shaft, J Bone Joint Surg 67A:857–64.
Freeland AE, Sud V, Jemison DM (2000) Early wrist arthrodesis for irreparable intra-
articular distal radial fractures, Hand Surg 5:113–18.
Friedlaender GE, Strong DM, Sell KW (1976) Studies on the antigenicity of bone: I.
Freeze-dried and deep frozen bone allografts in rabbits. J Bone Joint Surg 58A:854–8.
Friedlaender GE, Perry CR, Cole JD et al (2001) Osteogenic Protein-1 (Bone
Morphogenetic Protein-7) in the treatment of tibial nonunions, J Bone Joint Surg
83A(Suppl 1):151–8.
Gallay SH, McKee MD (2000) Operative treatment of nonunions about the elbow, Clin
Orthop 370:87–101.
Gazdag AR, Lane JM, Glaser D, Forster RA (1995) Alternatives to autogenous bone
graft: efficacy and indications, J Am Acad Orthop Surg 3:1–8.
Goss TP (1992) Current concepts review: fractures of the glenoid cavity, J Bone Joint
Surg 74A:299–305.
Grace TG, Eversmann WW (1980) The management of segmental bone loss associated
with forearm fractures, J Bone Joint Surg 62A:1150–5.
Gray JC, Elves MW (1979) Early osteogenesis in compact bone isografts: a quantitative
study of contributions of the different graft cells, Calcif Tissue Int 29:225–37.
Green SA (1994) Skeletal defects. A comparison of bone grafting and bone transport for
segmental skeletal defects, Clin Orthop 301:111–17.
Haddad RJ, Drez D (1974) Salvage procedures for defects in the forearm bones, Clin
Orthop 104:183–90.
Healy WL, Jupiter JB, Kristiansen TK, White RR (1990) Nonunion of the proximal
humerus. A review of 25 cases, J Orthop Trauma 4:424–31.
Helfet DL, Schmeling GJ (1993) Bicondylar intraarticular fractures of the distal humerus
in adults, Clin Orthop 292:26–36.
Highgenboten CL, Jackson A, Aschliman M, Meske NB (1989) The estimation of
femoral condyle size. An important component in osteochondral allografts, Clin
Orthop 246:225–33.
Inoue G, Tamura Y (1993) Osteosynthesis for longstanding nonunion of the lateral
humeral condyle, Arch Orthop Trauma Surg 112:236–8.
Johnson CA, Brown BA, Lasky LC (1985) Rh immunization caused by osseous allograft,
N Engl J Med 312:121–2.
Judet T, Richard L, Arnault O, De Thomasson E, Boury G (1992) Traitement des
pseudarthroses de tibia par décortication ostéopériostées de Robert Judet, Acta Orthop
Belg 58(Suppl I):182–6.
Keller EE, Triplett WW (1987) Iliac bone grafting: review of 160 consecutive cases. J
Oral Maxillofac Surg 45:11–14.
Kumar VP, Satku K, Helm R, Pho RWH (1988) Radial reconstruction in segmental
defects of both forearm bones, J Bone Joint Surg 70B:815–17.
Lacroix P (1945) Recent investigations on the growth of bone, Nature 156:576.
Lacroix P (1947) Organizers and the growth of bone, J Bone Joint Surg 29:292–6.
Lelie PN, Zaaijer HL, Cuypers HT (1996) Risk of virus transmission by tissue, blood and
plasma products Transplant Proc 28:2939.
Leung KS, Shen WY, Tsang HK et al (1990) An effective treatment of comminuted
fracture of the distal radius, J Hand Surg 15A:11–17.
Lim EVA, Lavaia WT, Robert JM (1996) Superior gluteal artery injury during iliac bone
grafting for spinal fusion; a case report and literature review, Spine 21:2376–8.
Lukash FN, Zingaro EA, Salig J (1974) The survival of free nonvascularized bone grafts
in irradiated areas by wrapping in muscle flaps, Plast Reconstr Surg 74:783–8.
Mathes SJ (1982) The muscle flap for management of osteomyelitis, N Engl J Med
306:294–5.
Mazur P (1984) Freezing of living cells: mechanisms and implications, Am J Physiol
247:C125–42.
McCrath MH, Watson KH (1981) Late results with local bone graft donor sites in hand
surgery, J Hand Surg 6:234–7.
McKee M, Jupiter J, Toh CL et al (1994) Reconstruction after malunion and nonunion of
intra-articular fractures of the distal humerus. Methods and results in 13 adults, J Bone
Joint Surg 76B:614–21.
McQueen M, Caspers J (1988) Colles’ fracture: Does the anatomic result affect the final
function?, J Bone Joint Surg 70B:649–51.
Miller RC, Phalen GS (1947) The repair of defects of the radius with fibular bone grafts,
J Bone Joint Surg 29:629–36.
Mirly HL, Manske PR, Szerzinski RN (1995) Distal radius bone graft in surgery of the
hand and wrist, J Hand Surg 20A:623–7.
Mullaji AB, Jupiter JB (1994) Low-contact dynamic compression plating of the clavicle,
Injury 25:41–5.
Mundy GR (1996) Regulation of bone formation by bone morphogenetic proteins and
other growth factors, Clin Orthop 324:24–8.
Murata Y, Takahashi K, Yamagata M, Shimada Y, Moriya H (2000) The anatomy of the
lateral femoral cutaneous nerve, with special reference to the harvesting of iliac bone
graft, J Bone Joint Surg 82A:746–7.
Nather A, Balasubramaniam P, Bose K (1990) Healing of non-vascularized diaphyseal
bone transplants. An experimental study, J Bone Joint Surg 72B:830–4.
Neo M, Matsushita M, Morita T, Nakamura T (2000) Pseudoaneurysm of the deep
circumflex iliac artery: a rare complication at an anterior iliac bone graft donor site,
Spine 25:848–51.
Nicoll EA (1956) The treatment of gaps in long bones by cancellous insert grafts, J Bone
Joint Surg 38B: 70–82.
Noellert RC, Louis DS (1985) Long-term follow-up of non-vascularized fibular
autografts for distal radial reconstruction, J Hand Surg 10A:335–40.
O’Connor B, Palmoski M, Brandt K (1985) Neurogenic acceleration of degenerative joint
lesions, J Bone Joint Surg 67A:562–72.
Oikarinen J (1982) Experimental spinal fusion with dccalcified bone matrix and deep
frozen allogeneic bone in rabbits, Clin Orthop 162:210–18.
Papagelopoulos PJ, Morrey BF (1994) Treatment of nonunion of olecranon fractures, J
Bone Joint Surg 76B:627–35.
Pelker RR, Friedlaender GE, Markham TC, Panjabi MM, Moen CJ (1984) Effects of
freezing and freeze-drying on the biomechanical properties of rat bone, J Orthop Res
1:405–11.
Prewett AB, Moyer MP, O’Leary RK, Mellonig JT (1992) Decalcification inactivates
HIV in spiked and infected bone, Trans Orthop Res Soc 17:436.
Puri R, Moskovich R, Gusmorino P, Shott S (2000) Bupivacaine for postoperative pain
relief at the iliac crest harvesting, Am J Orthop 29:443–6.
Ring D, Jupiter JB (1998) Current concepts review: fracture dislocation of the elbow, J
Rossillon R, Desmette D, Rombouts JJ (1999) Growth disturbance of the ilium after
splitting the iliac apophysis and iliac crest bone harvesting in children: a retrospective
study at the end of growth following unilateral Salter innominate osteotomy in 21
children, Acta Orthop Belg 65: 295–301.
Saleh M (1991) Bone graft harvesting: a percutaneous technique, J Bone Joint Surg
73B:867–8.
Smith RJ, Brushart TM (1985) Allograft bone for metacarpal reconstruction, J Hand Surg
10:325–34.
Smith SE, DeLee JC, Ramamurthy S (1984) Ilio-inguinal neuralgia following iliac bone
grafting, J Bone Joint Surg 66A:1306–8.
Springfield DS (1987) Massive autogenous bone grafts, Orthop Clin North Am 18:249–
56.
Stevenson S, Shaffer JW, Goldberg VM (1996) The humoral response to vascular and
nonvascular allografts of bone, Clin Orthop 326:86–95.
Szabo RM, Hotchkiss RN, Slater RR Jr (1997) The use of frozen-allograft radial head
replacement for treatment of established symptomatic proximal translation of the
radius. Preliminary experience in five cases, J Hand Surg 22A:269–78.
Tiedeman JJ, Connolly JF, Strates BS, Lippiello L (1991) Treatment of nonunion by
percutaneous injection of bone marrow and demineralized bone matrix. An
experimental study in dogs, Clin Orthop 268:294–302.
Tomford W (1995) Transmission of disease through transplantation of musculoskeletal
allografts, J Bone Joint Surg 77A:1742–54.
Tomford WW, Henry WB Jr, Trahan CA (1984) The fate of allograft articular cartilage:
fresh and frozen, Trans Orthop Res Soc 9:217.
Tomford WW, Bourret LA, Mankin HJ (1986) Investigations in cryopreservation of
articular cartilage, Trans Orthop Res Soc 11:111.
Urbaniak JR, Aitken M (1987) Clinical use of bone allografts in the elbow, Orthop Clin
North Am 18:311–21.
Urist MR, Silverman BF, Buring K, Dubuc FL, Rosenberg JM (1967) The bone induction
principle, Clin Orthop 53:243–83.
Verborgt O, Verellen K, Van Thielen F et al (2000) A retroperitoneal tumor as a late
complication of the use of bone wax, Acta Orthop Belg 66:389–91.
Vince KG, Miller JE (1987) Cross union complicating fracture of the forearm, J Bone
Joint Surg 69A:640–53.
Weber BG, Cech O (1976) Pseudoarthrosis. Hans Huber: Bern.
Wechel AM, Halsal MD (1977) Meralgia paresthetica: a complication of iliac bone
procurement, Plast Reconstr Surg 60:572–4.
Wilson D Jr (1972) A clinical study of the biomechanical behavior of massive bone

transplants used to reconstruct large bone defects, Clin Orthop 87:81–109.
World Health Organization (1992) Report of a WHO consultation on public health issue
related to animal and human spongiform encephalopathies, WHO/CDS/ VPH/92.104.
Geneva: World Health Organization
Wright RR, Schmeling GJ, Schwab JP (1997) The necessity of acute bone grafting in
diaphyseal forearm fractures. A retrospective review, J Orthop Trauma 11:288–94.
Wu CC, Shih CH (1992) Treatment for nonunion of the shaft of the humerus: comparison
of plates and Seidel interlocking nails, Can J Surg 35:661–5.
7
Massive bone defects of the upper limb:
reconstruction by vascularized bone
transfer
Michael B Wood
Introduction
The use of free microvascular bone segment transfer has become an accepted and, in
many instances, the preferred technique for reconstructing massive defects of bone. This
is true in either the upper or the lower limb. The advantages of this technique are
suggested to be more rapid bone union, more rapid bone hypertrophy and fewer instances
of late stress fracture or osteolysis. In addition, some authors suggest that microvascular
autografts may be used under adverse surgical conditions including a septic field or in an
irradiated field. The disadvantages of this technique are that microvascular bone transfer
is a technically demanding procedure and requires a donor site that may result in some
degree of morbidity. This chapter will focus on the indications and technique of
microvascular bone transfers in the upper limb, with illustrative case examples.
History
The suggestion of at least partial sustained viability of cellular elements within bone
segments transferred with an intact soft tissue vascular pedicle dates to at least a century
ago. Huntington in 1905 described the successful healing of a large tibial defect by a
pedicled shift of the ipsilateral fibula (Huntington 1905). Bone segments based on an
intact vascularized soft tissue pedicle lacked widespread clinical application, however,
because they were limited by the arc of rotation of the donor bone segment. It was not
until the clinical feasibility of microvascular anastomosis was demonstrated in the early
1960s that the concept of free vascularized bone grafting emerged. The earliest
experimental work using the rib as the model was by McCulloch in 1973 (McCulloch and
Fredrickson 1973). This was followed by the more comprehensive work of Östrup and
Fredrickson (1974). Several investigators subsequently confirmed earlier findings of at
least partial preservation of intraosseous cellular elements, a mechanism of bone union
more similar to fracture union than non-vascularized autograft incorporation and more
rapid bone remodeling (Doi et al 1977, Haw et al 1978, Berggren et al 1982, Arata et al
1984, Goldberg et al 1987, DeBoer and Wood 1989, Siegert and Wood 1990). Even
today, however, there remains a controversy about what the most important advantage of
a microvascular bone transfer is—whether it is retained intraosseous cellular viability or
whether it is the immediate re-establishment of intraosseous blood flow which permits

immediate reseeding of the bone segment with osteoprogenitor cells.
Clinical applications of microvascular bone transfer have been reported over the past
three decades. For long bone reconstruction, the fibula is clearly the preferred donor site.
Taylor is credited with the first report of a successful fibula transfer in 1975 (Taylor et al
1975). However, Ueba reported in 1983 what seems to be the first actual successful
clinical application (Ueba and Fuyikawa 1983). Regardless of who was the first to carry
out free fibular transfer, in the past 20 years, numerous large series have been reported
that have confirmed the value of this technique for reconstructing massive bone defects
(Gilbert 1979, Weiland et al 1979, 1983, Weiland 1981, Taylor 1983, Osterman and Bora
1984, Dell and Sheppard 1984, Wood and Cooney 1984, Wood et al 1984, 1985, Pho et
al 1985, Wood 1986, 1987, Gidumal et al 1987). The author’s personal series, reported
by Han et al (1992), resulted in an overall primary union rate of 61% and a secondary
union rate of 81%, with the best results occurring in non-septic reconstructions with a
union rate of 84%.
Upper limb bone defect—indications for vascularized bone transfer
In general, most authors suggest that the strongest indications for the use of vascularized
bone graft include situations that are prone to failure or complications with technically
less demanding techniques such as non-vascularized bone autografts or allografts. These
situations in general include massive defects and/or an unfavorable surrounding soft
tissue milieu related to prior bone grafting failure, infection, radiation or other causes of
extensive scarring.
Specific indications
Recipient site considerations

In the upper limb, humerus reconstruction probably represents the most compelling
indication for the use of vascularized fibula transfer. This is because, other than massive
allografts, there are few techniques available to reconstruct a large missing segment of
the humeral shaft. Although large defects of the radius and ulna may also be excellent
indications for reconstruction by vascularized bone transfer, the option of forearm
salvage by a one-bone forearm conversion (Fig. 1) always merits consideration (Peterson
et al 1995). Moreover, more limited defects of the proximal radius or distal ulna may be
consistent with an acceptable level of upper limb function.
Massive bone defects of the upper limb 87
Figure 1
One-bone forearm reconstruction for en bloc resection of
proximal radius.
Large bone defects

The precise length of a bony defect which would lead one to select a vascularized bone
graft for reconstruction is not particularly well established. Many authors (Taylor et al
1975, Weiland 1981, Osterman and Bora 1984, DeBoer and Wood 1989, Han et al 1992)
have suggested that a 6 cm gap is the point where vascularized bone reconstruction
should be chosen in place of a non-vascularized autograft. However, it is important to

recognize that with sufficient mechanical protection over several months, and when
dealing with a well vascularized surrounding soft tissue milieu, bone defects exceeding
10 cm may heal with cancellous autograft (Nicoll 1956) or non-vascularized cortical bone
segments (Enneking et al 1980). Moreover massive allografts may be a suitable option
for reconstructing very lengthy defects (Mankin et al 1987). However, it should be
recognized that massive allografts have limited ability to be revascularized and hence a
limited capacity to be replaced by ‘creeping substitution’ of host osteoprogenitor cells
(Phemister 1914). In general, the author believes that for a defect as short as 6 cm in the
presence of a poor surrounding soft tissue bed and for all defects greater than 10 cm, the
selection of vascularized bone transfer for reconstruction is justifiable.
Prior bone reconstruction failures

Bone defects in the upper limb, without regard to length, which have failed to heal with
nonvascularized autograft may be candidates for a vascularized bone graft. This is
particularly the case when there is no readily apparent explanation for the initial failure
(i.e. inadequate bone graft material, inadequate stabilization, use of allograft or xenograft,
etc.).
Infected bone defects

The use of vascularized bone grafts for reconstructing infected bone defects is
particularly attractive for a number of reasons. Probably the most important fact is that
such bone grafts are inherently a vehicle for local blood supply (Dell and Sheppard 1984,
Wood and Cooney 1984). However, also of importance is the fact that a vascularized
fibula is a generous source of bone length and it makes little difference from the technical
perspective if one transfers a 6 cm or 16 cm graft segment. Thus, a more aggressive
debridement of infected bone ends may be carried out with less concern about creating a
larger bone defect than can be reconstructed.
Non-unions associated with bone radionecrosis

Bone non-union that is associated with radiation osteonecrosis is a particularly
challenging problem that responds poorly to conventional bone grafting techniques
(Duffy 2000). This is because three adverse circumstances exist in the presence of
localized radiation changes: (1) impaired intraosseous blood supply; (2) impaired blood
supply of the surrounding soft tissue; (3) periosteal and intraosseous cell death. These
adverse circumstances are directly addressed by the transfer of vascularized bone
segment obtained from a site well distant to the irradiated field.
Donor sites
The focus of this chapter is repair of large bone defects of the upper limb. For all
practical purposes, for these types of defects, the fibula is the preferred donor bone.
Rarely is the fibula unavailable—for example, if both were previously harvested for bone
grafting or in unique patients with osteogenesis imperfecta. The technique of vascularized

fibula isolation has been well described (Gilbert 1979, Wood 1985) and will not be
repeated here. In the rare patient where the fibula is unavailable, one can consider other
vascularized bone donor sites for example, iliac crest, scapula, rib, radius, metatarsal or
any bone segment from a paralyzed or useless limb.
Surgical technique
Scapulo/humeral defects
Scapulohumeral defects most typically result from extraarticular resections of malignant
bone lesions of the proximal humerus. This situation presents significant technical
challenges in
Figure 2
(a) Parosteal osteogenic sarcoma of the proximal humerus.
(b) Immediate postoperative radiograph following
extraarticular resection of tumor and reconstruction with
massive proximal humerus allograft and side-by-side
vascularized fibular autograft bridging between scapula
and distal humerus. (c) Radiograph 7 years
postoperatively: note allograft, partial resorption and
progressive fibular hypertrophy. Solid scapulohumeral
union.
securing adequate fixation between the end of the transferred fibula and the remaining
scapula. The author has successfully used a compression plate and screws bridging from
the remaining scapular spine to the proximal segment of the fibula. However, due to the
cancellous nature of the scapula and small diameter of the fibula, such fixation requires
the additional use of external fixation using a shoulder spica cast. Because of the
problems associated with immobilization of this type of construct, the author prefers to
combine fibula transfer in this location with a proximal humerus allograft (Fig. 2). Such a
construct better ensures scapula to allograft and allograft to the remaining humerus
fixation by the use of larger screws and plates. The fibula
Figure 3
(a) Immediate postoperative radiograph following en bloc
resection of mid-humerus for chondrosarcoma and transfer
of revascularized fibular autograft. (b) Radiograph 13
months postoperatively. Note union and hypertrophy of
fibular segment to nearly the same diameter of normal
humerus.
is placed parallel to the allograft with contact proximally into the neck of the scapula and
distally to the remaining humerus, using a transosseous screw at each end. The author
prefers to revascularize the fibula in most patients by end-to-side anastomosis of the
donor bone peroneal artery to the recipient site brachial artery. Venous anastomoses are
usually end-to-end between peroneal venae comitantes and either brachial venae
comitantes or the cephalic vein. It is much easier to perform the vascular anastomoses
and to isolate the recipient vessels more distally in the upper limb. Thus, the fibular
segment should be positioned in a retrograde manner in order to position its vascular
pedicle closer to the elbow.
Figure 4
(a) Radiograph of atrophic non-union of humerus—prior
gunshot wound with extensive bone loss. (b) Immediate
postoperative radiograph of vascularized fibula transfer.
Note internal fixation with proximal and distal
compression plates.
Humeral diaphyseal defect

A large defect of the diaphysis of the humerus is probably the ideal application of
vascularized fibula transfer, because when successful it results in a functioning shoulder
and elbow joint. Typically defects of the humerus shaft result from penetrating trauma,
infected non-unions, tumor resection or radiation necrosis. Fixation of these constructs is
usually easier than with scapulohumeral defects. Preferentially, and when there is an
adequate remaining length of the proximal and distal humerus, a compression plate or
transosseous screws at each end is employed (Figs 3–5). If a compression plate is used at
each end screw fixation to at least six cortices (three screws, each with two cortex
purchase) should be obtained on either side of the osteosynthesis site. A single plate
spanning the entire construct should be avoided as it may act as a stress-shield and inhibit
appropriate fibular hypertrophy after healing. Even with compression plate fixation, the
additional protection of a shoulder spica cast should be considered for the first 2
postoperative months. As was mentioned for the scapulohumeral reconstructions,
retrograde positioning of the fibula should be done to facilitate access to the vascular
pedicle for anastomoses. Preferentially end-to-side arterial and end-to-end venous
anastomoses are employed as discussed previously.
Radius/ulna diaphyseal defect

Large defects of either radius or ulna most commonly result from penetrating trauma,
infected non-union or tumor resection. Based on size and shape considerations, the fibula
is a near perfect match for the diaphyseal segment of radius or ulna. Because of their
similarity, post-union hypertrophy of the fibular segment is usually not a significant
issue. Fixation may employ a compression plate and screws at each end or a single long
spanning plate may be utilized. If the latter technique is selected, however, it is important
to avoid screw placement in the central portion of the fibula or near the nutrient foramen.
Moreover, six-cortex fixation is required in both the distal and proximal forearm bone
segments whether one or two plates are used. For reconstruction requiring fixation to the
distal metaphyseal flare of the radius, it is preferable to dowel the fibula well into the
metaphysis of the radius (Fig. 6). Internal fixation by any method should be additionally
protected by the use of a long arm cast or splint for 6–8 weeks postoperatively. The
fibular segment may be placed orthograde or retrograde depending upon the most
convenient vascular access site. Anastomoses usually employ end-to-end coaptation to
either radial or ulnar arteries, provided the second vessel is patent and the superficial
palmar arterial arch permits adequate flow to all digits with the selected recipient artery
occluded. As a final comment, whenever one is considering the use of free vascularized
fibula for reconstructing a defect of either radius or ulna, the possibility of developing a
rather refractory radio-ulnar synostosis should be weighed—especially if the simpler
approach of a one-bone forearm construct is considered a viable option for the patient’s
functional needs and expectations.
Forearm-carpal defects
Forearm-carpal defects most often result from either penetrating trauma or aggressive
tumors, especially recurrent giant cell tumor of the distal radius. In this situation the usual
goal is to obtain a stable wrist arthrodesis (Fig. 7). The technique of vascularized bone
transfer in this area is essentially identical to that of reconstructing forearm defects, with
the exception of distal osteosynthesis fixation. It can be technically challenging to obtain
secure fixation to either the carpal bones or the metacarpals and the selection of the best
form of internal fixation will thus differ with the unique circumstances of each patient.
The author has utilized mini-plate fixation, screws alone, Kirschner wires and cerclage
wiring. In all patients firm cast support is recommended until union is confirmed.
Conclusion
Vascularized bone transfer is increasingly recognized as a very useful and versatile

technique for
Figure 5
(a) Radiograph of chronic non-union associated with
radionecrosis of humeral diaphysis for Ewing’s sarcoma.
(b) Immediate postoperative radiograph following
resection of radionecrotic humerus and transfer of
vascularized fibula autograft. (c) Radiograph of healed
humerus reconstruction 58 months postoperatively. Note
hypertrophy and absence of radionecrosis of humerus.
Figure 6
(a) Radiograph of radius—recurrent adamantinoma post
curettage at another institution. (b) Immediate
postoperative radiograph of en bloc resection of portion of
radius and transfer of vascularized fibula autograft. Note
intramedullary placement into metaphysis of radius. (c)
Radiograph 3 months postoperatively demonstrating union
of fibular autograft proximally and distally. (d) Radiograph
38 months post fibular transfer and 30 months post internal
fixation plate removal demonstrating fibula incorporation
identical to normal appearing radius.
Figure 7
(a) Radiograph of recurrent aggressive giant cell tumor of
distal radius invading proximal carpal row. (b) Immediate
postoperative radiograph following extraarticular en bloc
resection for aggressive, recurrent giant cell tumor of the
distal radius. Note distal fixation with multiple Kirschner
wires. (c) Radiograph 13 months postoperatively with
union proximally and distally and modest fibular
hypertrophy.
reconstructing massive bone defects in the upper limb or in patients with especially
challenging conditions, such as infected non-unions and nonunions associated with
radionecrosis of bone. It is especially indicated for the humerus and shoulder region with
more selected applications in the forearm or wrist. Though technically challenging, the
outcomes of this procedure justify consideration along with alternative methods for major
reconstructions of the upper limb.
References
Arata MA, Wood MB, Cooney WP (1984) Revascularized segmental bone transfers in
the canine. An analysis of viability, J Reconstruct Microsurg 1: 11–19.
Berggren A, Weiland AJ, Dorfman H (1982) The effect of prolonged ischemia time on
osteocyte and osteoblast survival in composite bone grafts revascularized by
microvascular anastomoses, Plast Reconstr Surg 69:290–8.
DeBoer NH, Wood MB (1989) Bone changes in the vascularized fibula graft, J Bone
Dell PC, Sheppard JE (1984) Vascularized bone grafts in the treatment of infected
forearm nonunions, J Hand Surg 9A:653–8.
Doi K, Tominaga S, Shubata T (1977) Bone grafts with microvascular anastomoses of
vascular pedicles: an experimental study in dogs, J Bone Joint Surg 59: 809–15.
Duffy GP, Wood MB, Rock MG, Sim FH (2000) Vascularized free fibular transfer
combined with autografting for the management of fracture nonunions associated with
radiation therapy, J Bone Joint Surg 82A:544–54.
Enneking WF, Gady GL, Burchardt H (1980) Autogenous cortical bone grafts in the
reconstruction of segmental skeletal defects, J Bone Joint Surg 62A: 1039–58.
Gidumal R, Wood MB, Sim FH et al (1987) Vascularized bone transfer for limb salvage
and reconstruction after resection of aggressive bone lesions, J Reconstr Microsurg
3:183–8.
Gilbert A (1979) Vascularized transfer of the fibular shaft, Int J Microsurg 1:100–2.
Goldberg VM, Shaffer JW, Field G, Davy DT (1987) Biology of vascularized bone
grafts, Orthop Clin North Am 18:197–205.
Han CS, Wood, MB, Bishop AT, Cooney WP (1992) Vascularized bone transfer, J Bone
Joint Surg 74A: 1441–9.
Haw CS, O’Brien B Mc, Kurata T (1978) The microsurgical revascularization of resected
segments of tibia in the dog, J Bone Joint Surg 60:266–9.
Huntington TW (1905) Case of bone transference. Use of a segment of fibula to supply a
defect in the tibia, Ann Surg 41:249.
Mankin HJ, Gebhardt MC, Tomford WW (1987) Use of frozen cadaveric allografts in the
management of patients with bone tumors of the extremities, Orthop Clin North Am
18:275–89.
McCulloch DW, Fredrickson JM (1973) Neovascularized rib grafts to reconstruct
mandibular defects, Can J Otolaryngol 2:96–100.
Nicoll GA (1956) The treatment of gaps in long bones by cancellous insert grafts, J Bone
Osterman AL, Bora FW (1984) Free vascularized bone grafting for large-gap nonunion
of long bones. Orthop Clin North Am 15:131–42.
Östrup LT, Fredrickson JM (1974) Distant transfer of a free living bone graft by
microvascular anastomosis: an experimental study, Plast Reconstr Surg 54:274–85.
Peterson CA, Maki S, Wood MB (1995) Clinical results of the one-bone forearm, J Hand
Surg 20A:609–18.
Phemister DB (1914) The fate of transplanted bone and regenerative powers of its
various constituents, Surg Gynecol Obstet 19:303–33.
Pho RW, Levack B, Satku K, Patradul A (1985) Free vascularized fibula graft in the
treatment of congenital pseudarthrosis of the tibia, J Bone Joint Surg 67B:64–70.
Siegert JJ, Wood MB (1990) Blood flow evaluation of vascularized bone transfers in a
canine model, J Orthop Res 8:291–6.
Taylor GI (1983) The current status of free vascularized bone grafts, Clin Plast Surg
10:185–209.
Taylor GI, Miller GDH, Ham FJ (1975) The free vascularized bone graft: a clinical
extension of microvascular techniques, Plast Reconstr Surg 55:533–44.
Ueba Y, Fuyikawa S (1983) Nine years follow-up of a vascularized fibular graft in
neurofibromatosis: a case report and literature review, Orthop Trauma Surg 26:595.
Weiland AJ (1981) Current concepts review. Vascularized free bone transplants, J Bone
Joint Surg 63A:166–9.
Weiland AJ, Kleinert HE, Kutz JE, Daniel RK (1979) Free vascularized bone grafts in
surgery of the upper extremity, J Hand Surg 4:129–44.
Weiland AJ, Moore JR, Daniel RK (1983) Vascularized bone autografts: experience with
41 cases, Clin Orthop 174:87–95.
Wood MB (1986) Free vascularized bone transfers for nonunion, segmental gaps, and
following tumor reconstruction, Orthopedics 9:810–16.
Wood MB (1987) Upper extremity reconstruction by vascularized bone transfers: results
and complications, J Hand Surg 12A:422–7.
Wood MB (1990) Free osseous tissue transfer. In: Atlas of Reconstructive Microsurgery.
Aspen Publications: Rockville, 65–91.
Wood MB, Cooney WP (1984) Vascularized bone segment transfers for management of
chronic osteomyelitis, Orthop Clin North Am 15:461–72.
Wood MB, Cooney WP, Irons GB (1984) Posttraumatic lower extremity reconstruction
by vascularized bone graft transfer, Orthopedics 7:255–62.
Wood MB, Cooney WP, Irons GB (1985) Skeletal reconstruction by vascularized bone
transfer. Indications and results, Mayo Clin Proc 60:729–34.
8
Loss of the post-traumatic infected
substance of the upper limb
Ferdinando Da Rin, Mauro Ciotti and Alain Gilbert
Introduction
The authors institute specializes in the treatment of chronic infected forms of

pseudoarthrosis and therefore of generally infected pseudoarthrosis. The institution was
set-up in 1932 by Professor Vittorio Putti, who wanted it for this purpose, in
collaboration with the Rizzoli Institute of Bologna. It remained in partnership until 1980
when it was taken over by the Veneto Region remaining, however, an important referral
centre for infected pathologies.
For the treatment of septic forms we introduced a therapeutic scheme some time ago,
based on the use of immuno-stimulation (Savoini 1972, 1975, Savoini et al 1980), a
necessary development following the continuously increasing resistance to antibiotics.
This therapy does not substitute and is used in association with the antibiotic treatment.
Figure 1
Pandiaphytes of ulna bone in an 11-year-old treated only
with ITBS and antibiotic therapy.
ITBS and antibiotic therapy
The ITBS (immuno therapy for specific bacteria) is based on the use of inactive
staphylococcus which stimulates the so-called aspecific immunity (Ciotti et al 1992)—
macrophages and lymphocyte helper cells stimulating the capacity for opsonization (Figs
Loss of the post-traumatic infected substance of the upper limb 101
1 and 2) and consists of subcutaneous injections, of gradually increasing doses for a

period of 3 months, that the patients can carry out by themselves at home.
We have verified a multitude of outcomes following the combined use of ITBS and
antibiotics. These can be summarized as follows:
• Spontaneous elimination of sequestrum.
• Demarcation and resorption of the area surrounding the focus of infection.
• Toning of the secretion.
• Tendency for the fistula to close.
• Reduction of the phenomenon of congestion.
Figure 2
1 year later: complete reconstruction of the ulna.
• Reduction of the new acute phase.

• Reduced articulation stiffness.
• Stimulation of bone repair.
• Improvement of the immunological condition with increase in the phagocytic activity
of macrophages and polymorphonucleated cells.
• Desensibilization of the bacterial proteins.
Along with this therapy we carry out local cleansing with antibiotics. A surgical clean-up
is always done following the ITBS.
The antibiotic therapy is carried out according to the antibiogram or culture where the
bacteria can be identified. Where the microorganism cannot be identified, we use high
doses of wide spectrum antibiotics.
Pseudoarthrosis
The loss of the bone substance or pseudoarthrosis, was defined according to the
parameters of
Figure 3
The typical atrophic form of pseudoarthrosis.
Weber and Cech (1989), as an absent consolidation after 6–8 months of the fracture. A
nonresolution of the fracture before this period is defined as a ‘delay of consolidation’.
Currently, the concept of pseudoarthrosis is different according to the location and the
anatomical–pathological characteristics of the type of bone interruption, and therefore
this is a statistical data and can change considerably. For this reason it is defined by
location and the radiological aspect of the injury (McKee 2000).
Once the pseudoarthrosis is established (nonunion) it may present in the following
forms:
• with or without loss of substance between the stumps of fracture
• with fragments of fracture (atrophic) (Fig. 3)
• with fragments of fracture (hypertrophic (Fig. 4)
This simple but practical classification allows us to consider some opportunities which
are provided by the fragmental characteristics of the
Figure 4
The hypertrophic form (the gap among the fragments is
important).
pseudoarthrosis and in fact, our treatment philosophy is based on these considerations:

1. A hypertrophic pseudoarthrosis without a gap between the fragments can be treated
by simple compression. In fact, the peculiar characteristic of this type of pathology is
its large regenerative potential, and that its stabilization alone can certainly result in
recovery.
2. An atrophic pseudoarthrosis, but with the fragments close to each other will certainly
need between and after stabilization.
3. In case there is a gap between the two fragments that does not exceed 5 cm, we will
consider approximation with compression using the apparatus of Ilizarov.
4. In the case of fragments separated by more than 5 cm, the solution is the transfer of
vascularized fibula.
Figure 5
Infected pseudoarthrosis of the right humerus with a
massive sequestrum and a gap between the fragments of
about 5 cm.
The surgical treatment in pseudoarthrosis must be immediate, because of the need to

stabilize the lesion. The antibiotic treatment and ITBS are started during the operation. In
septic forms without continuity, we can wait until the effect of the ITBS therapy. Stability
is our primary objective concomitantly with the treatment of the infection.
The loss of muscle and skin, nerve injury and associated tendon injury, are discussed
elsewhere in this book.
Treatment considerations of the various forms of pseudoarthrosis
Hypertrophic pseudoarthrosis with a gap less than 3–5 cm is treated with the Ilizarov
method.
If the gap measures 3 cm, we apply immediate compression to the focus of the
infection, because as described previously: ‘the infection burns at the firing of the
compression’. We use Ilizarov’s apparatus because usually we are dealing with a case of
poor alignment which must be corrected more than once and this apparatus permits us to
do so.
When the gap exceeds 5 cm (shortening is well tolerated by both the apparatus and the
patient), the compression is applied gradually, 3–4 mm each day, following an initial
compression which we do while in the operating theatre (Figs 5–7) for surgical cleaning
and removal of the sequestrum. If the focus of infection is oblique, it is necessary to use
the olive (Figs 8 and 9).
Figure 6
Application of the Ilizarov apparatus.
Figure 7(a,b)
After 15 days the contact between the fragments of the
pseudoarthrosis is seen and after 6 months the apparatus
was removed. This is the result 6 months after the removal.
Figure 8
Radiograph of Ilizarov’s apparatus and the olive for the
compression–stabilization of the focus while distraction is
taking place.
Obviously, this type of immediate compression can be applied for the pseudoarthrosis of
both bones of the forearm or of the humerus. If only one bone of the forearm is affected a
compacto tomy is performed and the and bone is moved to close the area of bone loss. If
the pseudoarthrosis is hypertrophic we do the compression and then some days later (15–
20 days) we do distraction of 1 mm of the same focus of pseudoarthrosis each day. Both
these techniques are used in the presence of a shortened bone (Figs 8–11).
Figure 9
Radiograph after 4 months of treatment shows correction
of the ulnar plus.
The proximal compactotomy technique with gradual distraction and compression of

the focus is shown in Figures 12–16. We must consider that the compression can or
better, must, take place very quickly. In fact, experience with lower limbs has shown, the
longer we take to put the fragments of pseudoarthrosis into contact, the higher the risk of
further consolidation, resulting in another operation to revitalize the fragments, mostly
with the use of cancellous bone graft
Figure 10
A pseudoarthrosis (infected) of the radius of a 43-year-old
patient: the outcome of an open fracture. (a) Radiographic
evidence of proximal migration of the radius (metry of
about 3 cm) with ulnar plus. (b) Following 7 months of
treatment, he has a fistula and laboratory tests show there
is an infection (VES: 55; PCR: 15; fibrinogen: 600).
Figure 11
Radiographs of the apparatus in compression, after 15–20
days of distraction of 1 mm per day.
.
Figures 17–19 show another case where we executed a simple compression followed
by gradual filling of the gap. This was preceded by a surgical cleaning and removal of a
sequestrum. We must also consider a system which is defined as ‘hybrid’ used for the
arm made up of rings in association with proximal fiches, like those used for the common
fixators (Fig. 17). This design
Figure 12
50-year-old male patient with an infected non-union
following an open fracture.
Figure 13
A model which shows the assembly required with the use
of a proximal compactotomy at the ends of the gap
between the fragments of pseudoarthrosis.
became obligatory after an initial use of the rings in proximity which was less tolerated
by the patient, as the rings occupied the medial side of the arm, preventing adduction and
producing painful subluxation of the shoulder.
Figure 14
Radiographs following application of Ilizarov apparatus,
the position of the compactotomy can be seen.
Figure 15
Radiograph of the contact of the fragments with the
evident formation of regenerated bone, and the closing of
the gap of about 5 cm.
In pseudoarthrosis with loss of substance, a gap of 5 cm for an upper limb is the limit
for direct compression of the focus. Exceeding this limit can lead to ischaemic
phenomena, especially on the distal side, due to an excessive kinking of vessels. This was
also demonstrated in Ilizarov’s work of 1959 (Ilizarov 1959, Dell and Sheppard 1984).
With an atrophic or hypertrophic loss of substance larger than 5 cm, we prefer to use
the vascularized fibula, which is considered the best method for bone reconstruction in
the upper limb (Dell and Sheppard 1984).
We use the vascularized fibula technique, because in the presence of septic pathology
Figure 16
Radiographic result after about 2 months of removal of the
apparatus.
Figure 17
Drawing representing the assembly called ‘hybrid’.
Figure 18
The skin incision.
there is a lack of vascularization, not just of the bone, but of the whole organ. Thus the
endoperiosteal vascularization of the fragment is compromised. The vascularization of
soft tissues is also compromised, since an infection above all results in hypoxaemia. The
focus of infection also tends to create isolating barriers, so that the antibiotics cannot
reach it.
If a non-vascularized graft is put into this environment, the survival of the graft itself
will be compromised. It may survive but after a long period, in which the defences
against possible intensification of the infection will be low and easily overcome by
microorganisms with low virulence. It is like being on a raft in the middle of the sea—
with (vascularized) or without (graft) provisions.
We follow the technique of Gilbert for this procedure, (1979, 1981, 1997) (Figs 18 and
19). We don’t use a particular technique if not the fixation of the focus, searching a
bayonet cap fixed with screws and eventually supported by an external fixer.
A particular method of using the fibula is to dissect the fibula, maintaining its
vascularization (Figs 20–22).
Before using the fibula, we do a first-step operation, using a spacer of cement with an
antibiotic because it is impossible to clean up the infection focus properly. In fact,
sometimes an infection with sequestration of the inserted fibula can occur (Fig. 23) when
the fibula is inserted immediately after the surgical cleaning. We must con-
Figure 19
Dissection of pedicle and section.
Figure 20
A particular case of the use the vascularized fibula in the
non-union of the distal humerus.
sider the difficulty in overcoming infection; thus the protocol adopted for this condition
consists of two steps. In the first step we do surgical cleaning and apply a spacer with an
antibiotic, which will be removed after 3–4 weeks after checking the local, general and
laboratory parameters. If these are still altered, we will substitute the spacer with another
spacer (Tripel 1986, McNally et al 1993, Tsukayama et al 1996). After the removal of the
spacer, in the second step we will transfer the vascularized fibula.
Figure 21
The cut in the middle of the fibula, without interruption of
its vascularization.
Figure 22
Reconstruction of the distal humerus.
The spacer serves many functions:

• it prevents adhesion between the fragments
• it maintains the correct length
• it contributes to the healing of the septic focus, maintaining high local concentration
of the antibiotic.
For a long time we used self mixed cements, which were composed of low toxicity
powdered antibiotics, but we noticed that these became porous (immediately leaching the
antibiotic) and fragile (Ghisellini and Ceffa 1997).
Figure 23
Infection of a fibula graft inserted immediately after
surgical cleaning. We resolved the situation by doing
surgical cleaning and applying Ilizarov’s apparatus.
Recently, cements have appeared on the market which are composed of two ready-
mixed antibiotics with a wide spectrum of action (Fig. 24) and have better biomechanical
properties. These cements are used especially in septic prosthesis replacements.
Complications
We have reported an intolerance to the Ilizarov device in a case where the ‘non-hybrid’
system has been utilized. The same also happened when the Ilizarov technique was
utilized for bone reconstruction, building up the gap after compactotomy.
Rare complications observed during limb ‘transfixation’ were lesions of a blood
vessel, a nerve or a tendon, all completely resolved after removal and substitution of
Kirschner wires. In one case a late brachial artery aneurysm needed a surgical repair of
the damaged vessel. In another case a forearm compartment syndrome resolved after the
removal of the Ilizarov device.
The eventual instability of the assembly needs periodic evaluation; also the
‘distraction’ of a bony fragment, if present, needs to be checked frequently since, in the
fibrous tissue, it could be blocked or deviated in its axis of descent. In this event an
incision must be performed along the wires or some corrective systems must be applied.
Tissue lysis and secretion around the wires is often seen. Usually it is a superficial
inflam-
Figure 24
Spectrum of action of a cement with gentamicin +
clindamicin.
Figure 25(a,b)
54-year-old patient—result of open fracture of the forearm
and wrist.
Figure 26
Fistulography.
Figure 27
Debridement and application of the spacer with external
fixator.
matory reaction that benefits from maintaining good hygiene of the device. A patient
must learn how to maintain hygiene.
Sometimes we have observed a flexion of the wrist or fingers, which can be avoided
by the use of splints attached to the Ilizarov device; this type of inconvenience resolves
completely after the removal of the device and some rehabilitation therapy.
The shortening of bone, mainly the humerus (even of 5 cm) was not followed by any
major functional defect.
Better results were obtained with the ‘twostep’ technique, mainly in the incidence of
relapse that reduced from 30% to 5%.
In the use of vascularized fibular graft for bone reconstruction, besides the difficulty
of harvesting, special attention must be given to the synthesis. For this to be made in the
safest and most stable way: we usually consider the use of synthesis screws together with
an external monoaxial fixator. In case of large bone loss the use of multihole plates
should be considered. No com
Figure 28
Removal of the spacer fibula microvascular graft with
arthrodesis of the wrist. After 4 months: removal of the
fixator. Radiograph after 2 more months.
plication has been reported in adult patients from graft sampling: in very few cases some
transient limitation of hallus abduction underwent spontaneous recovery.
A plexiform vascularization of the fibular vein could complicate the graft procedure,
requiring specific skills in vascular microsurgery for vascular calibre reduction. If
possible, the ligation of the receiving radial vessel should be avoided, performing two
termino-terminal sutures, proximal and distal, using the fibular artery as a bypass. In
elderly patients with history of cigarette-smoking and arteriopathy, microsurgery is
contraindicated.
References
Ciotti M, Argazzi M, Bergami PL (1992) La vaccinoterapia nell’ osteomielite cronica,

Atti SERTOT 34(Fasc II).
Dell PC, Sheppard JE (1984) Vascularized bone graft in the treatment of infected forearm
nonunions, J Hand Surg 9A:653.
Ghisellini F, Ceffa R (1997) Trattamento Delle Infezioni di Protesi Articolari. La
Moderna: Novara.
Gilbert A (1979) Vascularized transfer of the fibula shaft, Int J Microsurg 1:100–9.
Gilbert A (1981) Free vascularized bone graft. Int Surg 66:27.
Gilbert A (1997) Fibular transfer, In: Wood MB, Gilbert A eds. Microvascular Bone
Reconstruction. Martin Dunitz: London.
Ilizarov GA (1959) Compression osteosynthesis with the author’s apparatus in clinics (in
Russian), Final Scientific Session of the Institutes of Traumatology and Orthopedics
of Ministry of Health of the RSFSR. Leningrad, pp. 68–70.
McKee MD (2000) Aseptic non-union. In: AO Principles of Fracture Management.
Thieme: Stuttgart.
McNally MA, Small JO, Tofighi HG, Mollan RAB (1993) Two stage management of
chronic osteomyelitis of the long bones. The Belfast Technique, J Bone Joint Surg
75B:375–80.
Savoini E (1972) Sulla cura dell’osteomielite cronica, COM 60:547–69.
Savoini E (1975) Moderne Richtungen in der Behandlung der Chronischen
Osteomyelitis, Z Orthop 113:344–56.
Savoini E, Capanna R, Gherlinzoni F (1980) Immunità umorale ed osteomielite cronica,
COM 66:511–15.
Tripel SB (1986) Antibiotic-impregnate cement in total joint arthroplasty, J Bone Joint
Surg 68A:1297–302.
Tsukayama DT, Estrada R, Gustillo RB (1996) Infection after total hip arthroplasty, J
Bone Joint Surg 78A: 512–23.
Weber BG, Cech O (1989) Pseudoartrosi. Piccin: Padova.
9
Bone substitutes
Norbert Passuti, Laurence Bigotte, Sophie Touchais, Joël Delécrin and
François Gouin
Introduction
Bone grafting has a well recognized role in orthopaedic surgery for the treatment of
nonunion, bridging diaphyseal defects and filling metaphyseal defects. However, it is
associated with postoperative pain and morbidity (Summers and Eisenstein 1989,
Younger and Chapman 1989). When extensive grafting is required (as in spinal
arthrodesis and the management of large bony defects) adequate amounts of autologous
bone may not be available. Allograft bone has been used as an alternative but it has low
osteogenicity, increased immunogenicity and resorbs more rapidly than autogenous bone
and the transmission of disease remains a concern.
Autogenous bone graft is osteogenic, osteoinductive, osteoconductive and completely
biocompatible. These characteristics should also be present in the ideal substitute.
Osteogenic materials have the capacity to form bone, that is they have living cells such as
osteoblasts capable of producing it. Osteoconductive materials have no capability to form
bone or induce its formation.
Osteoconductive materials
Osteoconductive materials have been available for longer than osteoinductive or

osteogenic substitutes. These inert materials resemble the mineral phase of bone and are
biocompatible. They provide a structure or scaffold, which can form a close interface
with adjacent bone. The cellular elements can grow into the material and gradually
regenerate normal bone. They are generally used as a material to fill bone defects which
require mechanical support. However, some have a role in extending autogenous bone
graft, and more recently have been evaluated as carrier materials for osteoinductive
proteins.
Coralline hydroxyapatite
This material is derived from the calcium carbonate of sea corals. The pore structure of
coralline calcium phosphate produced by certain species is similar to human cancellous
bone, making it a suitable material for an osteoconductive substitute for bone graft. The
pore size required for bone ingrowth varies from 100 to 500 µm. Coralline bone
substitutes may be natural or manufactured. For the natural substitute the calcium
carbonate skeleton is harvested directly from the natural habitat, cleaned and sterilized.
Bone substitutes 121
The manufactured substitute is coralline hydroxyapatite, which is produced from natural

coralline calcium carbonate by substitution of the carbonate components with phosphates.
The material is commercially available and is marketed with mean pore sizes of 200 or
500 µm. It has high compressive strength but is brittle with low tensile strength. It has
been used in the management of fractures of the tibial plateau as a filler material and the
results have been comparable to those obtained with autogenous bone graft (Bucholz et al
1989). The main disadvantages have been the variable strength and rates of resorption.
More recently, coralline hydroxyapatite has been used as a carrier for some growth
factors. In a canine model, it has been used as a carrier for bone morphogenetic proteins
(BMP) with success and in a rabbit model as a carrier for transforming growth factors
and fibroblast growth factors (Miller et al 1991, Ashby et al 1996).
Calcium sulphate
This material is familiar to orthopaedic surgeons as plaster-of-Paris and is perhaps the
oldest osteoconductive material available. In a review of the history of the material, Tay
et al (1999) describe reports of it being used to fill bony defects in the last century. Its
main drawback is the chemical reaction which occurs during setting, and which results in
a very variable crystalline structure with consequent inconsistencies in the material
properties of the final product. It also resorbs very rapidly at a rate which may exceed the
capacity of surrounding bone to regenerate. At present, it has been superseded by more
reliable osteoinductive materials although it may still have a future role as a carrier for
BMP.
Ceramics
When naturally occurring mineral salts are subjected to very high temperatures in a
process known as sintering, highly crystalline materials termed ceramics are produced.
Some of these materials are biocompatible and osteoconductive. Their structure is quite
distinct from the poorly crystalline configuration of normal bone and for this reason they
are resorbed very slowly. The most popular ceramics have been tricalcium phosphate and
the derived ceramic hydroxyapatite. The latter is a biocompatible ceramic, which is
produced in a high temperature reaction and is a highly crystalline form of calcium
phosphate. It is very stable and resorbs very slowly. Coralline hydroxyapatite, which has
already been discussed, was one of the first ceramics to be used as an osteoconductive
material. The main drawbacks of ceramics are the slow resorption and the difficulty in
developing a material with favourable handling characteristics and which is easy to use
clinically.
Ceramics have been used in spinal surgery to extend autogenous bone graft in the long
fusion necessary for adolescent scoliosis. Le Huec et al (1997) compared the use of
tricalcium phosphate ceramic mixed with autogenous bone (24 patients) with a mixture of
allograft and autogenous bone (30 patients). No pseudoarthrosis occurred in either group.
Ransford et al (1998) carried out a randomized trial in 341 patients, comparing the use of
a synthetic porous ceramic with autogenous bone for spinal fusion in idiopathic scoliosis.
The results were comparable in both groups, but complications occurred in relation to the
donor site of the bone graft. The authors concluded that the ceramic was a safe and
effective substitute for autograft. The use of ceramic hydroxyapatite in the management
of fractures has been more limited. Itokazu et al 1996 found that in 17 patients with
fractures of the tibial plateau, the material was safe with no evidence of post-traumatic
arthritis at a mean follow-up of 2 years and 6 months.
The poor bioresorption and difficulties in the handling of ceramics have stimulated
research to develop materials which resemble the mineral phase of bone more closely.
This further has led to the development of calcium phosphate cements.
Calcium phosphate ceramics are widely used as bone graft substitutes for filling bone
defects because of their chemical composition which is similar to the mineral part of bone
and their excellent biocompatibility. They undergo a resorption/bone substitution process,
particularly when they are macroporous, and form a strong bond with the host bone
(Daculsi et al 1989b, 1990a). This property is known as bioactivity and has been
described by several authors (Daculsi et al 1989a). Bioactivity includes
biodegradation/dissolution of the ceramic and biological apatite precipitation. Many
factors influence the degradation/ dissolution process: physical form, composition and
crystallinity. The process of degradation/ dissolution results in physical changes (loss of
mechanical strength) and chemical changes (pH reduction in the implant environment
causing notably partial dissolution of the material). Dissolution provokes an elevation of
the calcium and phosphate ion concentrations in the microenvironment, leading to the
precipitation of a biological apatitic phase. The new microcrystals were observed
regardless of the site of implantation (osseous or non-osseous). However, no work has
clearly demonstrated the presence of ‘true bone’ in a non-osseous site and thus the
osteoinductivity of calcium phosphates. Differences in features between implants from
osseous and nonosseous sites.
To determine if physico-chemical changes participate in the modification of the
mechanical properties of macroporous biphasic calcium phosphate (MBCP), cylinders
were implanted in a bone site (rabbit femurs) where physicochemical changes and bone
ingrowth take place, and in muscle where only physico-chemical transformation occurs.
The presence of a new calcium phosphate phase and an organic matrix was observed by
FTIR (Fourier Transform Infrared) spectroscopy in both osseous and nonosseous site.
This new mineral phase was assumed to consist of bone apatite-like crystals. At the same
time compressive strength of MBCP, not only in bone but also in muscle increased
linearly with duration of implantation. Mechanical improvement of the MBCP implanted
in a human simultaneously with biological apatite precipitation was also demonstrated.
Factors that might explain this enhancement are decrease in microporosity and
precipitation of needle-like crystals, but transmission electron microscopy and
histological observations still have to be done to check that carbonated apatite
precipitates are the major changes in MBCP after implantation in muscle (Legeroz 1988).
Our results suggest that two types of multinucleated cells are elicited by contact with
the biomaterials implanted in bone site. The first type consists of large cells containing
more than 20 nuclei and resembling giant cells. These cells have neither TRAP (tartrate
resistant acid phosphatase) activity nor a ruffled border, but some have vacuoles or
vesicles with crystals, suggesting phagocytosis of the biomaterial. Similar cells have also
been observed with subcutaneous bone implants in rabbits. These multinucleated giant
cells do not have the specific enzymatic activity, cell surface aspects and functional
features of osteoclasts. The second type consists of multinucleated cells with some
characteristics similar to those of osteoclasts. These cells are smaller, contain less than 10
nuclei and are TRAP+. The enzyme activity of the cells appears to provoke extracellular
dissolution of the implant as demonstrated by the TRAP+ reaction and structural
modification in the biomaterials subjacent to the multinucleated cells. Electron
microscopy reveals that these cells have a clear zone and some cytoplasmic membrane
infolding resembling a ruffled border, was observed (Basle et al 1993).
The calcium phosphate ceramics HA (hydroxyapatite) and β-TCP (tricalcium
phosphate) are used clinically for bone reconstruction in periodontal, orthopaedic and
maxillofacial surgery. Biphasic calcium phosphate ceramic, being a mixture of HA and β-
TCP 1 is resorbable to a degree that is a function of the HA to β-TCP ratio. An animal
study showed that the biological performance of MBCP ceramics improved when they
were used in connection with repair of defects due to bone loss. Previous studies in which
we used non-commercial MBCP, consisting of HA-β-TCP in various proportions,
confirmed that the mixture of an equal amount of HA and β-TCP was particularly
effective. This explains why in both the experiments on animals and in this clinical study,
macroporous granules consisting of 60% HA and 40% β-TCP were used (Passuti et al
1989).
The histological results revealed bioactivity and osteoconduction in MBCP ceramics.
The granules became smaller with time; hence, resorption was taking place according to
the degree of β-TCP bioactivity and the stability of the HA. Following the biodegradation
and healing of the implanted site, the osteoblasts of the bone that received the implant
invaded the macropores and the spaces between the MBCP granules. True bone—
characterized by osteocytes, a mineralized bone matrix, and, because of remodelling, a
haversian-type system—appeared between the pores.
We observed that in general the newly formed bone appeared first on the surface area
of the MBCP granules and that it was made up mainly of lamellar bone and ‘scarcely
woven’ bone. In other human applications (spine fusion, long bone filling) we have
noticed the same results. According to our previous studies, it seems that 2 or 3 months
are needed before the new bone starts to look like normal bone (Trecant et al 1994).
Clinical experience
The initial Food and Drug Administration (FDA) monitored trial with Pro-Osteon
(Interpore Cross International, Irvine, CA, USA) consisted of 174 defects (137 acute
fractures, 26 delayed unions, 11 cysts) in 167 patients (Shors 1998). The inclusion of
patients with multiple aetiologies made data analysis difficult. More focused clinical
series have shown the efficacy of interporous hydroxyapatite (Bucholz et al 1989, Ladd
and Pliani 1999, Wolfe et al 1999). In a randomized study of 40 patients with split
depression tibial plateau fractures, hydroxyapatite implants were compared with autograft
in their ability to buttress articular fragments and prevent postoperative loss of reduction
(Bucholz et al 1989). Blocks of hydroxyapatite implants were milled to fit the different
shapes and volumes of defects encountered at surgery. No significant differences in the
clinical results were seen between hydroxyapatite implants and autograft. No
radiographic evidence of bioresorption of the implant was seen, even at long-term follow-
up. Similarly, in a study of 15 patients with severe distal radius fractures treated with
external fixation, supplemental Kirschner wires and limited open fixation, hydroxyapatite
implants were used to buttress depressed articular fragments (Wolfe et al 1999). The goal
of maintaining articular congruency was achieved. Intraarticular extrusion of
hydroxyapatite granules into the radio-carpal joint in one patient had no apparent adverse
effect on longterm wrist function. In a review of bone graft alternatives for complex
distal radius fractures, Ladd and Pliani (1999) concluded that hydroxyapatite implants are
useful, effective fillers.
Interporous hydroxyapatite has been used extensively in anterior and posterior spinal
arthrodesis. The FDA does not approve it for spinal use, and the series with spinal
applications are small (Thalgott et al 1999). Because of their weak mechanical properties,
granular hydroxyapatite implants are used primarily as bone graft extenders for long
posterior spinal arthrodesis with rigid instrumentation (Daculsi et al 1990b, Thalgott et al
1999)
Clinical applications for upper limb
Few publications describe specific applications of bone substitutes for traumatic defects
in the upper limb. Very often macroporous calcium phosphate ceramics are used for
filling bone defects (Gouin et al 1995) or for specific hand lesions as noted by
Schernberg et al (1992). They used a bovine derived ceramic substitute (Pyrost, Osteo
AG, Selzach, Switzerland) for 104 cases and suggested that this biomaterial can be
applied for bone defects in hand and wrist traumatology. In the case of acute fractures
prospective studies have been performed. A randomized clinical trial was concurrently
conducted at 18 medical centres to compare the safety and efficacy of two types of graft
material for the treatment of fractures of long bones: autogenous bone graft obtained
from the iliac crest and a composite material composed of purified bovine collagen, a
biphasic calcium phosphate ceramic and autogenous marrow. Two hundred and thirteen
patients were followed for a minimum of 24 months to monitor healing and occurrence of
complications. They observed no significant differences between the two treatment
groups with respect to rates of union or functional measures. Twelve patients, who were
treated with a synthetic graft had positive antibody titres to bovine collagen. The authors
concluded that for traumatic defects of long bones the use of the composite graft material
could be justified on the grounds of safety, efficacy (avoids the increased operative time)
and risk involved in obtaining an autogenous graft from the iliac crest (Chapman et al
1997).
For fractures of the distal radius some authors used bone cement (Sanchez-Sotelo et al
2000). They performed a prospective, randomized study on 110 patients more than 50
years old with fractures of the distal radius to compare the outcome of conservative
treatment with a bone cement (Norian skeletal repair system (SRS), Stratec Medical,
Germany) and immobilization in a cast for 2 weeks. Patients treated with SRS had less
pain and earlier restoration of movement and grip strength. The authors concluded that
injection of a remodellable bone cement into the trabecular defect of fractures of the
distal radius provided better radiological results than conventional treatment (Wolfe et al
1999). Hence traumatic bone defects can be filled with granules or blocks of
macroporous biphasic calcium phosphate ceramics mixed with bone marrow cells.
Example of a case
A 30-year-old female patient presented with a benign lesion of the first metacarpal bone
(Fig. 1). We filled the chondroma with macroporous biphasic calcium ceramic mixed
with bone marrow cells. After 13 months we observed
Figure 1
a satisfactory osteointegration of the bone substitute with consolidation (Figs 2 and 3).
Indications and future directions
Although interporous hydroxyapatite is only approved by the FDA for traumatic

metaphyseal defects, it has been used in the treatment of a spectrum of bone defect
problems including spinal arthrodesis, iliac crest donor site filler, delayed unions, non-
unions, bone cysts and tumors, and revision arthroplasties. The implant must be shielded
from major loading forces wherever it is applied. To date, all research and clinical
applications confirm it to be a biocompatible, osteoconductive, porous implant on which
bone has a propensity to grow (Bucholz et al 1989, Shors 1998, Wolfe et al 1999).
A resorbable form of the interporous hydroxyapatite called Pro-Osteon 500R
(Interpore Cross International, Irvine, CA, USA) has been devel-
Figure 2
Figure 3
An aspect of the bone rehabitation inside the macropores
of a calcium phosphate ceramic: biopsy done 2 years after
implantation. Ceramic in white, bone in grey
(differentiated bone inside the pores).
oped recently. By terminating the thermochemical reaction before completion, the coral
carbonate interior of the Goniopora coral is preserved with only the outer 4 µm of the
surface converting to hydroxyapatite.
Experimental data suggest that osteoblasts can degrade the coral carbonate much more
rapidly with resorption of most of the implant by 6 months. Although the mechanical
properties are similar to the original Pro-Osteon 500, the rapid resorption of Pro-Osteon
500R permits more complete bone remodelling. An autologous gel prepared from a
patient’s blood comprising of serum, serum-derived proteins and growth factors, and
platelets has been promoted and used as an adjuvant to form a composite graft with
osteoconductive interporous hydroxyapatite granules. No clinical series have been
published on the use of resorbable implants or plateletderived growth factor.
Biomaterials such as calcium phosphate ceramics appear to be suitable alternatives to
bone grafts. Calcium phosphate ceramics are known to be biocompatible and
osteoconductive: that is, they are able to promote new bone formation on contact (Daculsi
et al 1990b, Trecant et al 1994). Biphasic calcium phosphate (BCP) ceramics, composed
of a mixture of hydroxyapatite and 13-tricalcium phosphate, are considered to be more
bioactive (Daculsi et al 1999) and more efficient than hydroxyapatite alone for the repair
of periodontal defects (Ellinger et al 1986), certain orthopaedic applications (Daculsi and
Passuti 1990), and maxillofacial and ear, nose, and throat surgery. The macroporous form
of BCP can promote bone formation by osteoconduction and has a degradation rate
adapted to bone ingrowth kinetics (Ellinger et al 1986, Daculsi and Passuti 1990).
However, these ceramics possess no intrinsic osteogenic (osteoinduction) properties.
Therefore, they are inadequate for the filling of large bone defects or lesions, especially
since they have little contact with bone, which means that clinical applications may have
to be restricted to small bone defects or to regions with large bone contact. The
association of osteogenic cells with calcium phosphate ceramics has shown osteogenic
potential in vivo, as illustrated in a rat model of bone marrow cells and calcium
phosphate ceramic that induced bone formation in extraosseous sites (Nade et al 1983)
and also potentiated bone ingrowth in osseous sites (Benayahu et al 1991).
Bone marrow contains various cell populations involved in both bone homoeostasis
and renewal of peripheral mature blood cells. Thus, in addition to osteoprogenitors, bone
marrow contains various mesenchymal cells, including fibroblasts, adipocytes,
endothelial cells, smooth muscle cells and reticular cells (Benayahu et al 1991). The
osteogenic potential of the mesenchymal stem cell compartment has been demonstrated
by Friedenstein et al (1968). It differentiated to form an ossicle in association with active
haematopoietic tissue when grafted under the kidney capsule. In vitro, human and animal
mesenchymal stem cells have differentiated into osteogenic cells, giving rise to bone-like
tissues (Maniatopoulos 1988). These results suggest that bone marrow cells are good
candidates for improving the osteoinductive capacity of biomaterials. Moreover, bone
marrow can be obtained much more easily from patients than can autologous bone. We
cultured bone marrow mesenchymal stem cells on biomaterials in order to obtain a
‘hybrid material’ with osteogenic potential. The proliferation of mesenchymal stem cells
and their differentiation in calcium phosphate ceramic, leading to in vitro autologous
bone formation, should allow the use of this material in many new clinical applications.
Conclusions
Bone graft substitutes of two main types are now available. Osteoinductive materials
incorporate a BMP in a carrier material, which, after implantation, induces local tissue to
form bone. Osteoconductive materials are an inert scaffold which allows bony ingrowth
from local osseous tissue. Some of these products have compressive strengths similar to
that of cancellous bone. Many are still being evaluated experimentally. There is
increasing interest in combining an osteoinductive protein in an osteoconductive carrier
medium with more desirable structural properties. It is probable that a second generation
of products with these characteristics will appear in the foreseeable future. At present,
osteoconductive materials have been shown to be effective in the treatment of defects in
metaphyseal bone in association with some fractures, notably in the distal radius, the
tibial plateau and the calcaneum. Osteogenic proteins have met with some success in the
treatment of bone defects and non-union, but more work is needed to define the most
effective protein and the optimum local dose required.
Autologous bone grafting will, for the moment, continue to play an important role in
the treatment of non-union. In the future, however, it seems likely that the requirement
for this treatment will diminish and with the development of more effective alternatives it
may eventually become obsolete.
References
Ashby ER, Rudkin GH, Ishida K, Miller TA (1996) Evaluation of a novel osteogenic
factor, bone cell stimulating substance in a rabbit cranial defect model, Plast Reconstr
Surg 98:420–6.
Basle MF, Chappard D, Grizon F et al (1993) Osteoclastic resorption of Ca-P
biomaterials implanted in rabbit bone, Calcif Tissue Int 53:348–56.
Benayahu D, Fried A, Zipori D, Weintroub S (1991) Subpopulation of marrow stromal
cells share a variety of osteoblastic markers, Calcif Tiss Int 49:202–7.
Bucholz RW, Carlton A, Holmes RE (1989) Interporous hydroxyapatite as a bone graft
substitute in tibial plateau fractures, Clin Orthop Rel Res 240:53–62.
Chapman MW, Bucholz R, Cornell CH (1997) Treatment of acute fractures with a
collagen-calcium phosphate graft material: a randomized clinical trial, J Bone Joint
Surg (Am) 79A:495–502.
Daculsi G, Passuti N (1990) Effect of the macroporosity for osseous substitution of
calcium phosphate ceramics, Biomaterials 11:86–7.
Daculsi G, Legeros G, Nery E et al (1989a) Transformation of biphasic calcium
phosphate ceramics in vivo: ultrastructural and physicochemical characterization, J
Biomed Mater Res 23:883–94.
Daculsi G, Passuti N, Martin S, Le Nihouanen JC, Brulliard V, Delécrin J (1989b) Etude
comparative des céramiques biocalciques en phosphate de calcium après implantation
en site spongieux chez le chien, Rev Chir Orthop 75:65–71.
Daculsi G, Legeros RZ, Heughebaert M, Barbieux I (1990a) Formation of carbonate
apatite crystals after implanatation of calcium phosphate ceramics. Calcif Tissue Int
46:20–7.
Daculsi G, Passuti N, Martin S et al (1990b) Macroporous calcium phosphate ceramic for
long bone surgery in humans and dogs. Clinical and histological study, J Biomed
Mater Res 24:379–96.
Ellinger RF, Nery EB, Lynch KL (1986) Histological assessments of periodontal osseous
defects following implantation of hydroxyapatite and biphasic calcium phosphate
ceramics. A case report, Int J Periodont Restor Dent 3:223.
Friedenstein AJ, Petrakova KV, Kurolesova AI et al (1968) Heterotopic transplants of
bone marrow. Analysis of precursor cells for osteogenic and hematopoietic tissues,
Transplantation 6:230–47.
Gouin F, Delécrin J, Passuti N et al (1995) Comblements osseux par céramique
phosphocalcique biphasée macroporeuse. A propos de 23 cas , Rev Chir Orthop
81:59–65.
Itokazu M, Matsunaga T, Ishii M, Kusakabe H, Wyni Y (1996) Use of arthroscopy and
interporous hydroxyapatite as a bone graft substitute in tibial plateau fractures, Acta
Orthop Traum Surg 115:45–8.
Ladd A, Pliani N (1999) Use of bone graft substitutes in distal radius fractures, J Am
Acad Orthop Surg 7:279–90.
Legeros RZ (1988) Calcium phosphate materials in restorative dentistry: a review, Adv
Dent Res 2:164–80.
Le Huec JC, Lespirt E, Delavigne C et al (1997) Tricalcium phosphate ceramics and
allografts as bone substitutes for spinal fusion in idiopathic scoliosis: comparative
results at four years, Acta Orthop Belg 63:202–11.
Maniatopoulos C, Sodek S, Melcher AH (1988) Bone formation in vitro by stroma cells
obtained from bone marrow of young adult rats, Cell Tiss Res 254: 317–30.
Miller TA, Ishida K, Kobayashi M et al (1991) The induction of bone by an osteogenic
protein and the conduction of bone by porous hydroxyapatite: a laboratory study in the
rabbit, Plast Reconstr Surg 87:87–95.
Nade S, Armstrong L, McCartney E, Baggaley B (1983) Osteogenesis after bone and
bone marrow transplantation. The ability of ceramic materials to sustain osteogenesis
from transplanted bone marrow cells: preliminary studies, Clin Orthop 181:255–63.
Passuti N, Daculsi G, Rogez JM et al (1989) Macroporous calcium phosphate ceramic
performance in human spine fusion, Clin Orthop Rel Res 248: 169–76.
Ransford AO, Morley T, Edgar MA et al (1998) Synthetic porous ceramic compared with
autograft in scoliosis surgery: a prospective randomized study of 341 patients, J Bone
Joint Surg (Br) 80B:13–18.
Sanchez-Sotelo J, Munuera L, Madero R (2000) Treatment of fractures of distal radius
with a remodellable bone cement: a prospective randomised study using Norian SRS,
J Bone Joint Surg (Br) 82B: 856–63.
Schernberg F, Costa-Foru B, Magnien C (1992) Utilisation d’un substitut osseux (Pyrost)
au niveau de la main. Résultats préliminaires à 3 ans. Communication à la Société
Française de Chirurgie de la Main, Montpellier.
Shors E (1998) Bone graft substitutes: clinical studies using coralline hydroxyapatite
biomaterials in surgery. In: Walenkamp GHIM, Bakker FC, eds. Georg Thieme
Verlag: Stuttgart, 83–9.
Summers BN, Eisenstein SM (1989) Donor site pain from the ilium: a complication of
lumbar spine fusion, J Bone Joint Surg (Br) 71B:677–80.
Tay B, Patel VV, Bradford DS (1999) Calcium sulphate and calcium phosphate-based
bone substitutes: mimicry of the mineral phase of bone, Orthop Clin North Am
30:615–23.
Thalgott S, Fritts K, Guiffre J, Timlin M (1999) Anterior interbody fusion of the cervical
spinal with coralline hydroxyapatite. Spine 24:1295–9.
Trecant M, Delecrin J, Royer J, Daculsi G (1994) Mechanical changes in macroporous
calcium phosphate ceramics after implantation in bone, Clin Mater 15:233–40.
Wolfe S, Pike L, Slade J, Katz L (1999) Augmentation of distal radius fracture fixation
with coralline hydroxyapatite bone graft substitute, J Hand Surg 24A:816–27.
Younger EM, Chapman MW (1989) Morbidity at bone graft donor sites, J Orthop
Trauma 3:192–5.
Joint reconstruction
10
Joint transfers and joint reconstruction
Luc Téot
Introduction
Joints which have lost normal movements consequent to traumatic arthrodesis or

congenital malformations are candidates for surgical reconstruction. Several techniques
have been proposed to restore movement in joints using different types of transfer like
partial or complete replacement of joints by allografts or epiphyseal replacements using
pedicled apophysis on growing bones. Limitations of these techniques include the
anatomical scarcity of donor sites (autografts, allografts) and the poor scientific evidence
of the revascularization of the transplanted structure. However, clinical results have
confirmed that these surgical techniques can improve the movements in reconstructed
joints.
Fundamental aspects
Two different types of osteochondral transfer can be performed, that is bone allografts
without preservation of the vascularization and free epiphyseal partial reconstruction
using vascularized growing structures. Both these techniques are based on a specific
behaviour, linked to the cellular events occurring in the transplanted zone.
Bone allografts are subject to the immunogenicity of the patient and its long-term
effects on graft preservation (Friedlaender 1987). Bone incorporation can be divided into
several stages. First, the inflammatory response is predominant, initiated by the antigen
reactions and surgery, leading to an infiltration of lymphocytes (T cells). Then the graft is
surrounded by fibrovascular tissue which leads to the revascularization of the graft. The
rejection process is observed mostly over the surface of the cortical bone. Osteolysis and
osteogenesis must proceed in delicate balance, in order to prevent a rapid rejection and to
enhance the repopulation of osteoblasts from the recipient. When the rejection process is
more pronounced, the bone is weakened (Friedlaender 1983). The immune response is
not a significant factor in a patient with chronic resorption and increased susceptibility to
infection (Enneking and Mindell 1991).
Burchardt (1987) proposed a scheme to differentiate the three types of bone reaction
after allograft bone transplantation.
• type I—(20%), the bone behaves like an autograft
• type II—(60%), the bone is slowly resorbed
• type III—(20%), rapid resorption of the bone graft is observed.
Joint transfers and joint reconstruction 133
In most cases, the rejection process is limited to several millimetres of the depth of the
bone.
Cartilage allografts follow the same principles as bone allografts but some additional
requirements are:
• Histological and biomechanical characteristics of the recipient bed must be respected.
The homology of the situation is important, an elbow replacing an elbow. Osmotic
exchanges and cartilage nutrition are favoured, certainly by a correct cartilage
massage (Poitout 1996).
• The cartilage matrix must be intact, as immunological reactions are favoured by any
surface alteration. The modality of cryo-preservation is important to obtain living
chondrocytes.
Joint transfer
Non-pedicled allografts
Several authors have suggested the use of nonvascularized allografts, with or without
simultaneous soft tissue flap coverage (Mastorakos et al 2002) after tumour resection.
Flap coverage can be done immediately or can be delayed. In Mastorakos et al’s series,
12 patients had such a technique after resection of a tumour involving the upper limb.
The overall limb salvage rate for the bone allograft and soft tissue flap coverage was
95%. Alman (1995) used massive allografts to reconstruct the epiphysis. In a series of 26
patients, 12 had allografts placed in the upper limb. Sixtynine per cent of the total
patients had a good result in spite of a 77% complication rate and 54% had a fracture at
the site of the allografted bone.
Slow resorption is frequently observed and fractures and non-union are not rare.
Movements of flexion–extension can be usefully restored, with some limitation in the full
range of motion.
Allograft elbow transfer seems to be done more than any other upper limb joint
transfer. Indications are rare, and most of them are posttraumatic situations where the
joint was completely destroyed. Preparation of the recipient site can be problematic. In
some cases, the skin can be severely retracted. Skin expanders are often necessary to
progressively enlarge the recipient cavity before transfer. The skin can be a source of
problems when incisions or retractile adherent scars cross the elbow area. In these cases,
a large muscle flap like the latissimus dorsi pedicled flap will protect the transferred joint
against exposure and provide good vascularization to the skin. Some authors stress the
importance of the muscular envelope, and insist on a large vascularized muscle flap,
when the muscles surrounding the allografted transfer seem inadequate.
Skin volume also has to be checked before transfer in order not to limit the freedom of
movements.
Composite tissue allografts for the human hand are a subject of controversy, and very
few studies have measured precisely the exact range of motion of the transplanted joints
included in the hand transfer. Some information was recently put forward by Siemionow
and Ozer (2002). Urbaniak et al (1987) described the results in their series of elbow
allografts to be poor. However, Marck (2001) reported recently on the experience of two
different French units of 12 complete allografts of the elbow. Indications for elbow
allograft were discussed and compared to arthrodesis, arthroplastic resection and
prosthetic arthroplasty. The author concluded that allogeneic arthroplasty can be
proposed for large losses of osteocartilaginous substance. The rate of complications,
especially the rate of sepsis, is high (more than 50% of joint destruction). Plans to
overcome the anticipation of the skin problems must be made carefully. The mean
follow-up was 9 years in their series. In the
Figure 1
long term the transfer is marked by a chronic dislocation (mechanical, immunological) of

the joint partially compensated by the muscles surrounding the joint. Functional results
were good, in spite of poor radiological findings (Fig. 1). Conclusions were positive,
specially concerning the restoration of bone around the cartilage in case of large defects.
Other proposals were put forward from these studies, particularly the possibility of
combining bone allografts with prosthetic replacement of the cartilaginous surfaces.
Epiphyseal transfer
Non-pedicled epiphyseal autograft

Maruthainar et al presented in 2002 a series of 13 patients with large tumour of the lower
radial epiphysis (giant cell tumours, osteosarcoma, chondrosarcoma and Ewing’s
sarcomas) where the upper fibula was transferred without its own vascularization. Results
were satisfactory in terms of function.
Pedicled epiphysis
Three areas can be considered as potential donor sites for epiphyseal transfers: the lower
scapular apophysis, the iliac crest (anterior or posterior) and the upper fibula (Figs 2 and
3).
The upper fibular epiphysis is mostly used in adults to reconstruct significant defects
of the radius, especially following resection of giant cell tumours, and was proposed by
several authors to reconstruct the upper humerus after malignant tumour resections. Pho
et al (1988) and Innocenti et al (1998) used the upper fibular
Figure 2
Figure 3
Figure 4
epiphysis as a vascularized transplant to replace the upper humerus and the distal radius
after tumour resection (Fig. 4).
The iliac crest was used for the reconstruction of the lower femoral epiphysis and the
acetabular rim area, and in congenital malformations of the radius. Studies carried out
during the past 20 years lead to new information on physiology and behaviour of the
transplanted growth area. In congenital malformations, growth of the transplanted
structure approximates the deficient growth of the malformed limb, especially when the
transfer is placed in apposition to the abnormal epiphysis. In complete replacements of an
absent growth plate the expected growth cannot be compared to the normal contralateral
side (Fig. 5). In a recent series published by Gilbert and Mathoulin (2000), indications for
epiphyseal replacements were summarized as follows: fibula can be proposed in upper
limb reconstruction and iliac crest for lower limb growth plate replacement.
The lower scapular apophysis has been used in different indications of radial club
hand. Téot et al (1992) published a series where the scapular apophysis was used as an
appositional graft to increase the volume and the surface of some epiphyses in congenital
malformations. In the upper limb, the vascularized scapular apophysis was used in
apposition to the distal ulna in a radial club hand. The result after a 19-year follow-up,
shows the amount growth compared to the growth of the malformed ulna (Fig. 6).
Hemitransfers were proposed by Harpf (2002) to rebuild the normal shape of the great
toe and increase the web size after vascularized transplantation in five adult patients. The
technique used the fibular part of the great toe and its adjacent soft tissue and the first
web space. Results showed an improvement of the pinch up to 90% of the strength of the
normal contralateral side.
Discussion
The choice of the technique in joint transfer or joint reconstruction is dependent on

different factors such as the anatomical location, the aetiology of the joint destruction or
loss of movements, the softness and pliability of the skin surrounding the joint and the
quality of the muscles.
When dealing with reconstruction of the wrist, most authors will choose pedicled
transfer coming from the upper fibula if the defect is long and the scapular crest or the
iliac crest if the
Figure 5
defect is limited. For reconstruction of the elbow allografts are preferred. The upper
humeral epiphysis can be replaced either by vascularized fibular transplantation or
allograft. The elbow joint is difficult to replace, due to the shape of the bone extremities
and the specificites of the two different types of joint. In this case, the discussion of the
options with the patient must be comprehensive and include the choices of prosthetic
replacement and allograft reconstruction.
Figure 6
Absence of movement can either be the consequence of an extensive epiphyseo-

diaphyseal resection; or of limited trauma involving the cartilage, leading to a
spontaneous arthrodesis (where a limited osteochondral graft can provide enough tissue
to restore the movement); or of congenital malformations (where movement has never
been possible due to simultaneous limitations of the tendon’s course.
The surrounding tissues influence the results. Joint replacement under fibrous tissue or
scarred adherent skin will lead to a poor result. Replacement of these tissues before or
during the joint reconstruction is necessary.
Some authors recommended the association of an allograft transfer to a vascularized
autograft, especially for shoulder and knee replacements to enhance muscular ambience
and to provide a better protection against infection (Zinberg et al 1985).
Autologous transfers have been used since Judet in 1908. Large series (Elderlyi) of
nonvascularized autologous transfers were instructive in term of biological data. As for
bone transfers, the sequence of revascularizationrejection was observed. Movement is
necessary to prevent ankylosis of the joint, but would be deleterious if excessive before
complete revascularization. Experimental studies on pigs (Yoshuzi) could compare
partially vascularized joint transfers to completely devascularized transfers. A destruction
of the cartilage is observed in most of the devascularized group, contrary to the
vascularized group. Results of transplantations of small joints seemed completely
dependent on the revascularization process, contrary to what is observed after large joint
transplantations.
Epiphyseal transfers including a growing structure have been developed since 1976,
with the confirmation that the preservation of the epiphyseal vessels was mandatory to
expect normal growth. Experimental transplantation and replantation of complete and
partial epiphysis were carried out by Brown et al, Zaleske et al, and Téot (Zaleske et al
1982, Brown et al 1983). Results showed good preservation of growth when the complete
epiphyseal vascularization was maintained during the transfer, and that growth plate
physiology was complex and cellular events quite different in the peripheral part
compared to the central part of the structure. Anatomical studies concerning the lower
scapula (Téot et al 1981), the upper fibular epiphysis and the iliac crest (Téot 1982) were
carried out in child cadavers using injection techniques.
Conclusion
Joint transfer and joint reconstruction have demonstrated their usefulness and their
technical reliability. Problems remain concerning donor sites, immunologic control and
revascularization. The future of allocartilage transplantation, combined with the progress
in resorbable biomaterials could open new possibilities in joint reconstruction.
References
Allieu Y, Chammas M, Desbonnet P (2000) Elbow allograft and their long term results.
In: Hand Arthroplasties. Martin Dunitz: London.
Bugbee WD (2002) Fresh osteochondral allografts, J Knee Surg 15:191–5.
Brown K, Marie P, Lyskakowski T, Daniel R, Cruess R (1983) Epiphyseal growth after
free fibular transfer with and without anastomoses, J Bone Joint Surg 65B:493.
Burchardt H (1987) Biology of bone transplantation, Orthop Clin North Am 18:187–96.
Chow SP, Chan KC, Tang SC, Billett (1986) Reconstruction of the lateral tibial condyle
by a pedicled vascularized fibular graft after en bloc resection of giant cell tumour, Int
Orthop 10:239–43.
Enneking WF, Mindell ER (1991) Observations on massive retrieved human allografts, J
Entin MA, Alger JR, Baird RM (1962) Experimental and clinical transplantation of
autogenous whole joints, J Bone Joint Surg 44A:1518.
Friedlaender GE (1983) Immune response to osteochondral allografts: current knowledge

and future directions, Clin Orthop 174:58–68.
Friedlaender GE (1987) Bone grafts: the basic science rationale for clinical applications,
J Bone Joint Surg 69A:786–90.
Germain MA, Dubousset J, Mascard E, Kalifa C (2000) Vascularized peroneal
reconstruction after bloc resection of tumors or congenital malformations of the upper
limb in children, Bull Acad Natl Med 184: 1671–84.
Getty PJ, Peabody TD (1999) Complications and functional outcomes of reconstruction
with an osteoarticular allograft after intra-articular resection of the proximal aspect of
the humerus, J Bone Joint Surg (Am) 81:1138–46.
Gilbert A, Mathoulin C (2000) Vascularized bone grafts in children. Specifics and
indications, Ann Chir Plast Esthet 45:309–2.
Herndon GH, Chase W (1952) Experimental studies in the transplantation of whole
joints, J Bone Joint Surg 34A:564.
Innocenti M, Ceruso M, Manfrini M et al (1998) J Reconstr Microsurg 14:137–43.
Marck G (2001) Les allogreffes totales de l’articulation du coude Etude à long terme a
propos de 12 cas. Thèse Marseille.
Maruthainar N, Zambakidis C, Harper G, Calder D, Cannon SR, Briggs TW (2002)
Functional outcome following excision of tumours of the distal radius and
reconstruction by autologous non-vascularized osteoarticular fibula grafting, J Hand
Surg (Br) 27: 171–4.
Mastorakos DP, Disa JJ, Athanasian E, Boland P, Healey JH, Cordeiro PG (2002) Soft-
tissue flap coverage maximizes limb salvage after allograft bone extremity
reconstruction, Plast Reconstr Surg 109:1567–73.
Minami A, Kato H, Iwasaki N (2002) Vascularized fibular graft after excision of giant-
cell tumor of the distal radius: wrist arthroplasty versus partial wrist arthrodesis, Plast
Nagoya S, Usui M, Wada T, Yamashita T, Ishii S (2000) Reconstruction and limb
salvage using a free vascularised fibular graft for periacetabular malignant bone
tumours, J Bone Joint Surg (Br) 82:1121–4.
Pho RW, Patterson MH, Kour AK, Kumar VP (1988) Free vascularized epiphyseal
transplantation in upper extremity reconstruction, J Hand Surg (Br) 13:440–7.
Poitout DG (1996) Avenir des allogreffes osseuses dans les résections osseuses massives
pour tumeur, Presse Med 25:527–30.
Rodl RW, Ozaki T, Hoffmann C, Bottner F, Lindner N, Winkelmann W (2000)
Osteoarticular allograft in surgery for high-grade malignant tumours of bone, J Bone
Joint Surg (Br) 82:1006–10.
Shea KG, Coleman DA, Scott SM, Coleman SS, Christianson M (1997)
Microvascularized free fibular grafts for reconstruction of skeletal defects after tumor
resection, J Pediatr Orthop 17:424–3.
Shigetomi M, Hickey MJ, Hurley JV, Riccio M, Niazi ZB, Ohta I (1996) Orthotopic
vascularized osteochondral allografts in an immunosuppressed rat model, J Reconstr
Siemionow M, Ozer K (2002) Advances in composite tissue allograft transplantation as
related to the hand and upper extremity, J Hand Surg (Am) 27:565–80.
Téot L (1982) Les transferts osseux libres vascularisés de cartilage de croissance, Rev
Chir Orthop 61(Suppl 2):40–2.
Téot L, Bossé JP, Mouffarège R, Papillon J (1981) The scapular bone crest pedicled bone
graft, Int J Microsurg 3:257.
Téot L, Bossé JP, Dussault RG, Gilbert A (1983) Pedicled iliac crest epiphysis
transplantation, Clin Orthop 180:286–93.
Téot L, Souyris F, Bossé JP (1992) Pedicle scapular apophysis transplantation in
congenital limb malformations. Ann Plast Surg 29:332–40.
Urbaniak JR et al (1987) Clinical use of bone allograft in the elbow, Orthop Clin North
Am 18:311–21.
Wada T, Usui M, Isu K, Yamawakii S, Ishii S (1999) Reconstruction and limb salvage
after resection for malignant bone tumour of the proximal humerus. A sling procedure
using a free vascularised fibular graft, J Bone Joint Surg (Br) 81:808–13.
Zaleske PJ, Ehrlich MG, Piliero C, May J, Mankin H (1982) Growth plate behavior in
whole joint replantation in the rabbit, J Bone Joint Surg 64A:249.
Zinberg EM, Wood MB, Brown ML (1985) Vascularized bone transfer: evaluation of
viability by postoperative bone scan, J Reconstr Microsurg 2:13–19.
11
Joint replacement as a secondary
procedure
John K Stanley and Ian A Trail
Joint replacement for traumatic bone loss at the elbow
Fractures around the elbow are quite common but those that involve loss of bone
substance are relatively rare. Fractures, in which there is a loss of bone, may be divided
into three main categories:
1. The closed grossly comminuted fracture and non-union.
2. The pathological fracture.
3. The side-swipe or gunshot wound.
There is no doubt that the alternatives for treatment of significant traumatic bone loss at
the elbow are limited, consisting basically of the five ‘As’:
• Autograft
• Allograft
• Arthroplasty
• Arthrodesis
• Amputation.
The closed fracture

In situations in which it is impossible to reconstruct the fracture (or where the fracture
has a very low chance of healing such as in the elderly) and fragments are discarded at
the time of surgery, the potential benefits and risks of a primary joint replacement must
be assessed.
This most commonly occurs when there is a complex comminuted fracture of the
radial head associated with medial collateral ligament injury and a fracture of the
coronoid process. The grossly unstable situation requires a sound radial head that is
achieved with primary radial head replacement and fixation of the coronoid fragment. If
there is a significant axial compression element to the injury the Essex-Lopresti lesion
(Essex-Lopresti 1951) may exist (fracture of the radial head and rupture of the radio-ulna
interosseous membrane). It is then imperative to restore axial length to the radius to
prevent proximal migration of the radius leading to increased ulna plus variance and ulna
abutment syndrome. If the radial head is not reconstructable, radial head replacement is
indicated. The choice of implant is a matter of personal experience. Currently viable
implants are manufactured from cobalt-chrome, stainless steel, pyrolytic carbon and
titanium, pyrolytic carbon alone and titanium alone. The implants may be modular or
Joint replacement as a secondary procedure 143
monobloc; cemented or uncemented. However, whichever implant is chosen must be

rigid and not deformable such as those made from silicone rubber.
The indications for primary total elbow replacement in the management of fractures
are well outlined by Morrey and others (Figgie et al 1989, Morrey and Adams 1992,
Garcia et al 2002) and may be summarized as (1) elderly patients with low transverse or
‘Y’ shaped intercondylar fractures which have a poor reputation for healing in these
patients, and (2) those who have already gone on to delayed or non-union (Figgie et al
1989, Morrey and Adams 1992). The lower age limit is a matter for judgement but in the
absence of any significant comorbidity patients under the age of 70 years would require
further justification, in addition to age and the type of fracture. Morrey cites rheumatoid
arthritis and other inflammatory joint disease as two of the conditions, which if present,
would tilt the
Figure 1
(a) Loss of bone at 1 year following a low humeral fracture
in an elderly woman. The lower humerus was barely a
shell at operation with no ligamentous support and with a
painful non-union. (b) Stability was restored with a linked
modular implant (c,d) Range of pain-free motion at 3
months.
balance in favour of total arthroplasty rather than open reduction and internal fixation. In
his series the youngest patient was 40 years old and had concomitant rheumatoid disease.
The choice of implant in these circumstances will be determined by the surgeon’s
preference and by the state of the remaining bone and restraining ligaments. In general a
linked ‘sloppy hinge’ the so-called semi-constrained implant, for example the Acclaim
(DePuy) or Coonrad– Morrey (Zimmer), is necessary to provide stability in joints in
which the soft tissue envelope cannot provide sufficient support for a resurfacing implant.
In the event that there is sufficient soft tissue restraint, it is possible to use a resurfacing
implant and Acclaim (DePuy), Kudo (Biomet), GSBIII (Sultzer), Souter/Strathclyde
(Stryker-Howmedica) are examples of implants available in this configuration. It is for
more reliable to treat these comminuted fractures conservatively with a plaster followed
by an orthosis and to consider the options at leisure than to rush to perform an
arthroplasty. However, individual treatment decisions depend on each patient’s unique
requirements and primary surgery is more likely in the older, more frail patient (Fig. 1).
The pathological fracture

If a traumatic event precipitates a fracture through an area where the tumour or disease
has destroyed the bone structure in such a way that reconstruction with autograft is
impossible or, that the reconstruction would be so complex that only in the very young
adult would one consider such a procedure, then implant arthroplasty should be
considered (Morrey 1985). In these circumstances a custom implant is indicated (Venable
1952). In the majority of patients a linked ‘sloppy hinge’ is the implant of choice. Peri-
prosthetic fracture in the rheumatoid osteoporotic patient is an example of a benign
condition causing significant bone loss. In the absence of infection a combination of a
distal humeral allograft and a long-stemmed linked ‘sloppy hinge’ is a realistic although a
very challenging procedure even for the greatly experienced elbow surgeon. David
Stanley (Sheffield, UK) cautiously reports early success with this technique. With the
advent of more extensive ranges
Figure 2
(a) Massive bone loss due to a periprosthetic fracture. (b)
Stabilization with a linked snap fit revision prosthesis.
of stem size and length, considerable defects in the humerus can be bridged with an
implant but on occasion a custom implant may be necessary. The nature of the pathology
causing the defect has a significant influence upon the decision to proceed with an
implant arthroplasty, particularly in the younger patient. For example, neoplasia with
poor prognosis would shift the balance toward a replacement rather than a major
reconstructive procedure (Fig. 2).
The side-swipe or gunshot wound

This is a situation where the bone is lost at the time of the traumatic event and is not
recoverable. Five common complications of these serious injuries increase the difficulty
of the management:
• the fractures are often compound and contaminated
• there are often significant neurological injuries
• there is commonly a vascular injury
• large soft tissue defects may be present
• significant skin loss is often present.

In the hours immediately following these injuries the treatment is often determined by the
extent of the vascular injury and the urgency of repair and restoration of adequate
perfusion of the forearm and hand. The stabilization of the humerus to the radius and ulna
is necessary to protect the anastomoses. Therefore it is necessary to consider extensive
open reduction and internal fixation at this time. Primary total joint replacement is
contraindicated. However, an external fixator can be applied although such a device
would introduce potential pin track contamination and increase the risk of infection and
stiffness. Nicholas et al (1993) and Brannon et al (1995) advise early removal of such
devices.
The place of joint replacement in the treatment of these injuries is very small indeed
because of proven bush wear from the linked prostheses (Brannon et al 1995) and the
potential for fracture of the implant in the younger age group (< 60 years) who invariably
have higher demands. However, there are special circumstances such as the case of a 39-
year-old soldier quoted by Jupiter and Morrey (2000). He had severe bilateral elbow
injuries with an amputation on one side and arthrodesis on the other, grossly impaired
function and severe disability. An elbow arthroplasty was performed and the soldier’s
function improved dramatically with the caveat that some form of rebushing or revision
some time in the future would almost certainly be required.
Joint replacement for traumatic bone loss at the shoulder
The use of shoulder arthroplasty to manage the sequelae of trauma at the shoulder has
been undertaken for some time (Neer et al 1982). The development of pain and stiffness
together with secondary osteoarthritis following three and four part fracture of the
shoulder is well known, being seen particularly where the fracture heals in malunion or
where there is avascular necrosis. Occasionally fractures at this site can go on to non-
union.
Traditionally ‘monobloc’ type prosthesis such as the Neer has been used. More
recently however with the advent of modular prosthesis implants designed specifically
for use in trauma or post trauma have become available (Global, FX, Aequalis, Polaris).
Whilst, undoubtedly, these new prostheses have facilitated the procedure at this time
there is no evidence that they have improved the outcome. The latter is related to a
number of factors primarily the severity of the initial injury, the delay between the injury
and the insertion of an arthroplasty as well as the age of the patient. There is no doubt
that if surgery is undertaken primarily the results are generally more favourable. In light
of this it is of paramount importance to make the correct operative decision at the time of
injury. Generally for three or four part fractures of the humeral head, the choice lies
between either some form of internal fixation or arthroplasty. For a displaced four part
fracture, particularly fracture dislocation, in the older patient it would seem sensible to
proceed directly to arthroplasty. For the younger patient whilst internal fixation obviously
offers more potential advantages, much depends on the quality of the fixation, the
requirement for bone graft and the vascularity of the fragments, etc.
Figure 3
(a) Bone collapse due to osteoporosis with a four part
fracture. (b) Treatment with a hemi-arthroplasty.
Again if this proves difficult speedy conversion to arthroplasty may be an option.

The preoperative planning can be aided considerably by a CT scan, which gives more
detailed information of the severity of the injury, particularly the number and position of
fragments. If an arthroplasty is planned this should be undertaken in the standard fashion
taking all routine precautions to limit the complication of infection. Of particular
difficulty when undertaking arthroplasty in this situation is the assessment of the correct
rotation of the humeral component, its height above the fracture line and finally fixation
of both tuberosities to either the implant, the humeral shaft or both.
With regard to rotation most surgeons would use the elbow and forearm as a guide
allowing the implant to be inserted in 30° of retroversion. With regard to the height with
the shoulder reduced the inferior border of the humeral head should lie at the same
horizontal level as the lower border of the glenoid without undue tension. The newer
implant designs provide a ‘jig’ system, which facilitates this part of the procedure. Once
the correct humeral component has been chosen it should be cemented into place.
Generally the use of methylmethacrylate is recommended, as this is the only means of
obtaining a secure fixation to the humeral shaft.
The authors would also recommend an advanced cementing technique where possible.
The next step with modular systems is to choose the correct head size. A good guide for
this is the humeral head that has been removed. Most systems contain a measuring guide,
which allows this to be done. It is important however, that the head size used is not too
large as this can cause postoperative stiffness—more specifically, with the trial head in
situ, the shoulder laxity should be as close to normal as possible; that is the head should
translate to the rim of the glenoid both posteriorly and inferiorly and be stable on external
rotation to 60°. Generally a glenoid component is not inserted unless there is significant
change in the glenoid articular surface.
The final and most difficult step however, is reattachment of the tuberosities
particularly the greater tuberosity. Several systems are now available and involve the use
of either wire or strong suture passed through bone or the rotator cuff and sutured down
on to the prosthesis, humerus or both. On many occasions there is an obvious gap
between the tuberosity and the humeral shaft. Within this area it is important to minimize
cement and, if appropriate, de-bulk the tuberosity. The latter allows it to sit better onto
the shaft; the defect is then bridged by a bone graft taken from the excised humeral head.
With regard to the immediate postoperative period many surgeons will immobilize the
shoulder in an abduction splint, this is analogous to the position following a rotator cuff
repair and certainly would de-tension the tuberosity repair. Otherwise passive
mobilization is started immediately.
Neer et al (1982) drew attention to the specific difficulties in treating patients who had
suffered sequelae of trauma to the shoulder. These difficulties were related to the
presence of contracture and scarring of the muscles, the presence of nerve injuries and
shortening of the humeral shaft. If the malunited tuberosity required osteotomy the
rehabilitation programme was slowed and recovery prolonged.
Further to this Huten and Duparc (1986) reported their experience with 22 old injuries
of the shoulder in which they used a Neer prosthesis. The mean age of the patients was 66
years. They reported a number of complications which included dislocation, secondary
displacement of fragment and loosening of the glenoid component: some of these
requiring further surgery. Movements were limited with less than half achieving flexion
to 90°. Radiologically, as well as loosening of the glenoid component, a number of
humeral components were subluxated proximally indicating rupture of the rotator cuff.
Overall the authors concluded that the results in acute situations were better than in
chronic situations.
Frich et al (1991) reported a similar series, reporting unpredictable pain relief in the
delayed group with only 22% of this group having a good result as evaluated by the
modified Neer scoring system. Again, there were a number of cases of persistent
instability particularly when the arthroplasty followed failed osteosynthesis. Norris et al
(1995) reported their results in 23 patients with failed treatment of three and four part
proximal humeral fractures subsequently treated with prosthetic arthroplasty. They were
able to show a reduction in pain level, and an increase in active forward elevation from
68° to 92° and in active external rotation from 6° to 27°. Whilst this resulted in an
improvement for most patients’ functional activities, they did note that late surgery is
technically difficult and the results are inferior to those for acute humeral head
replacement. Nevertheless they recommended that late arthroplasty is a satisfactory
reconstruct option. Bosch et al (1998) reported somewhat better results although they
again found a significant correlation between the outcome and the length of time between
the injury and arthroplasty.
Boileau et al (2001) reported their multicentre study of 71 cases. In their series the
average time between initial fracture and shoulder arthroplasty was 5 years and 5 months.
On the basis of radiographical examination they developed a classification system which
found:
1. Humeral head collapse or necrosis with minimal tuberosity malunion.
2. Locked dislocations or fracture dislocations.
3. Non-union of the surgical neck.
4. Severe malunions of the tuberosities.
Overall the postoperative Constant score was good to excellent in 42% of cases; patient
satisfaction was generally good. The limiting factor in functional outcome was whether a
greater tuberosity osteotomy had been done. Specifically, they felt that if the greater
tuberosity was left in situ rather than undergoing an osteotomy the results were better.
Further basic research was undertaken by Frankle et al (2001) who showed in the
laboratory situation that if the greater and lesser tuberosities were replaced in an
anatomical position the outcome was superior than if they were placed or left in a
nonanatomical position.
Work from the authors’ institution shows that over the past 10 years 36 patients have
undergone shoulder arthroplasty as a result of the sequelae of trauma. The majority of
these patients were over 60 years of age. In most cases the fracture system (Global FX)
was used. At review the visual analogue score for pain was reduced from a preoperative
value of 7.3 to 2.7 at follow-up. Abduction improved from 43° to 84° and flexion from
49° to 94° and external rotation also improved from 7° to 35°. As a result func
Figure 4
(a) Fracture with avascular necrosis, rotator cuff failure
and glenoid deficiency. (b) Total joint replacement with a
high riding humeral head.
tion (as measured by the American Shoulder and Elbow Society and Constant scoring
systems) was improved. The overall survival at 10 years was 69%. A number of revisions
have been undertaken for various complications: loosening of the glenoid, dislocation,
infection and superior migration as a result of rotator cuff tuberosity failure (Fig. 4). As a
result of this it is our view that whilst arthroplasty undoubtedly has a valuable role in the
treatment of sequelae of trauma the results are not as good as those of arthroplasty in
primary osteoarthritis. Added to this is a significant complication rate; many of the
complications requiring further surgery.
Non-union of the humeral fracture can also be treated by arthroplasty. Results of this
treatment were reported by Antuna et al (2002) who evaluated the outcome of 25
replacement with a 6-year follow-up. Most patients had experienced significant pain
relief and improvement in active elevation from 41° to 88° and in external rotation from
22° to 38° Overall the modified Neer scoring system showed that there were 12
satisfactory and excellent results.
References
Antuna SA, Sperling JW, Sanchez-Sotelo J, Cofield RH (2002) Shoulder arthroplasty for
proximal humeral nonunions, J Shoulder Elbow Surg 11:114–21.
Boileau P, Trojani C, Walch G, Krishnan SG, Romeo A, Sinnerton R (2001) Shoulder
arthroplasty for the treatment of the sequelae of fractures of the proximal humerus, J
Shoulder Elbow Surg 10:299–308.
Bosch U, Skutek M, Fremerey R, Tscherne H (1998) Outcome after primary and
secondary hemiathroplasty in elderly patients with fractures of the proximal humerus,
J Shoulder Elbow Surg 7:479–84.
Brannon JK, Woods C, Chandran RE, Hansrai KK, Reyes CS (1995) Gunshot wounds to
the elbow, Orthop Clin North Am 26:75–84.
Cooney WP (2000) Reconstructive procedures of the elbow. In: Morrey BF, ed. The
Elbow and its Disorders, 3rd edn. 583–601.
Essex-Lopresti P (1951) Fractures of the radial head with distal radio-ulnar dislocation, J
Bone Joint Surg 33B:244.
Figgie MP, Inglis AE, Mow CS, Figgie HE (1989) Salvage of non-union of
supracondylar fracture of the humerus by total elbow arthroplasty, J Bone Joint Surg
71A:1058–65.
Frankle MA, Greenwald DP, Markee BA, Ondrovic LE, Lee WE (2001) Biomechanical
effects of malposition of tuberosity fragments on the humeral prosthetic reconstruction
for four-part proximal humeral fractures, J Shoulder Elbow Surg 10:321–6.
Frich LH, Sojbjerg JO, Sneppen O (1991) Shoulder arthroplasty in complex acute and
chronic proximal humeral fractures, Orthopedics 14:949–54.
Galatz LM, Iannotti JP (2000) Management of surgical neck nonunions, Orthop Clin
North Am 31:51–61.
Garcia JA, Mykula R, Stanley D (2002) Complex fractures of the distal humerus in the
elderly. The role of total elbow replacement as primary treatment, J Bone Joint Surg
(Br) 84:812–16.
Huten D, Duparc J (1986) Prosthetic arthroplasty for acute and old injuries to the
shoulder, Rev Chir Orthop 72:517–29.
Jupiter J, Morrey BF (2000) Fractures of the distal humerus in adults. In: Morrey BF, ed.
The Elbow and its Disorders, 3rd edn. 325.
Morrey BF (1985) Reconstructive procedures of the elbow. In: Morrey BF, ed. The
Elbow and its Disorders, 1st edn. 570–81.
Morrey BF, Adams RA (1992) Semi-constrained total elbow replacement for distal
humeral non-union, J Bone Joint Surg 77B:67–72.
Neer CS, Watson KC, Stantont PJ (1982) Recent experience in total shoulder
replacement, J Bone Joint Surg 64A3:319–37.
Nicholas RM, Barr RJ, Mollan RA (1993) Paramilitary punishment in Northern Ireland: a
macabre irony, J Trauma 34:90–5.
Norris TR, Green A, McGuigan FX (1995) Late prosthetic shoulder arthroplasty for
displaced proximal humerus fractures, J Shoulder Elbow Surg 4:271–80.
Siegel JA, Dines DM (2000) Proximal humerus malunions, Orthop Clin North Am
31:35–49.
Venable CS (1952) An elbow and an elbow prosthesis: case of complete loss of the lower
third of the humerus, Am J Surg 83:271.
12
Joint fusion in severe traumatic defects of
the upper limb
Giorgio A Brunelli
Joint fusion (arthrodesis) is tantamount to a confession of the surgeon that he is not able
to perform effective reconstructive surgery of that joint (i.e. reconstruction or
replacement of the joint or restitution of the motors) (Botteri 1960).
In arthrodesis, any movement of the joint is abolished and the damaged, useless,
painful joint is transformed to a rigid painless lever. By the suppression of the normal
movement of a joint, arthrodesis provides a stable connection of the bones that
constituted that joint, removes pain and allows the patient to exploit the movements of
nearby joints and the remaining muscles.
Arthrodesis is not a common operation. Generally, sacrificing a joint repulses the
surgeon, but it is a matter of ‘propitiatory sacrifice’ offered to obtain active movement of
an irretrievable joint, especially the glenohumeral joint. Joint fusions have strict
indications and require perfect surgical technique and expertise during both the operation
and the postoperative treatment. Indications for joint fusion are as follows:
• loss of bony components of the joint
• comminuted fractures of the bone heads
• severe, irreparable ruptures of the ligaments and instability
• painful arthritis (idiopathic or post-traumatic)
• severe infections of the joint (resistant to medical treatment, especially after open
fractures)
• paralysis of the motors of the joint
• necessity of doing heavy work
• refusal or impossibility of joint replacement.
The contraindications of joint fusion are: old age and a person’s psychological refusal of
treatment of a stiff joint and/or of the loss of movement.
Arthrodesis may be classified as extraarticular, intraarticular or mixed. It can be
simple or modelled, i.e., performed in such a way so as to give particularly favourable
positions postoperatively. It can be done by decortication alone or with the addition of
bone grafts. Numerous types of arthrodesis have been suggested, and the positions of the
arthrodesis of the shoulder, the elbow and the wrist have been discussed in the literature
for a long time.
Joint fusion in severe traumatic defects of the upper limb 153
Techniques of joint fusion
A joint fusion may be done by:

• Resecting the articular cartilage and the cortical bone beneath, moulding the bone ends
to obtain a good congruence, putting them in contact with each other and forcing and
maintaining the contact by means of plasters, compression plates, screws (Richards et
al 1963) or combination of both, nails or external fixators (Charnley 1966, Johnson et
al 1986, Nagano 1989).
• Adding bony grafts to this moulding (either corticocancellous bone blocks or
corticocancellous chips or better of a cancellous bone ‘paste’ (Brunelli 1972) obtained
by pounding cancellous bone).
• Turning aside or sliding corticocancellous flaps from one of the involved bones (Brille
2001).
• Putting extraarticular bone grafts (rare option today).
• Performing a free microvascular bone graft when the loss of bone is excessive or the
recipient bed is sclerotic and avascular.
• All these methods may be used with specific alterations for the different joints of the
upper limb.
Shoulder
Among the joint fusions of the upper limb, the arthrodesis of the shoulder gives the best
results provided it is done properly and the motors of the scapula function. It is the joint
fusion that does better than the others. By suppressing the movement of the joint it
restitutes the movement to the arm. The first shoulder arthrodesis was probably done by
Albert in 1879.
The shoulder joint may require arthrodesis for the following indications:
• comminuted fractures
• traumatic loss of the humeral head in compound fractures
• surgical removal of the humeral head (tumours, infections)
• failures of shoulder replacement
• palsy of the motors of the shoulder due to brachial plexus lesions.
Pre-requiste conditions for arthrodesis of the shoulder joint are:
• Good function of thoracoscapular muscles: trapezium, levator scapulae, rhomboid and
particularly serratus anterior.
• The function of the pectoralis major must also be satisfactory because its presence is
fundamental for the thoracobrachial grip.
• Good function of the distal arm. It is of no use to perform a shoulder arthrodesis if the
hand is completely paralysed and flail.
• Integrity of the other joints of the shoulder (acromioclavicular, sternoclavicular and
scapulothoracic joints). Stiffness of these joints following joint fractures or adhesion
of the scapula to thorax impairs or annuls the result. It is therefore very important to
take care to avoid any involvement of the acromioclavicular joint during surgery.
Joints which substitute for the glenohumeral articulation are subject to extra work and
may undergo deterioration and degenerative arthritis
Figure 1
The ideal position to be given to a shoulder arthrodesis. (a)
20° of internal rotation (to allow the patient to touch the
abdomen). (b) 20° of abduction (60° if calculated from the
external edge of the scapula and humerus shaft). This fixed
abduction will allow the arm to dangle close to the thorax
and to abduct up to 70° by the movements of the scapula.
(c) 45° of anteposition.
with time; the muscles also undergo extra stress, sometimes reacting by undergoing
hypertrophy and sometimes with exhaustion and atrophy.
It is mandatory to choose the best position tailored for the requirements of the patient.
After shoulder fusion we must obtain an abduction sufficient to position the hand on the
working plane yet not to prevent an efficient active adduction for the thoracobrachial
plyers which must be strong enough to hold an object under the axilla. (Hawkins and
Neer 1987, Harryman et al 1993).
Furthermore, too much abduction will cause muscle fatigue. I believe that the arm
must be put in 20–40° of abduction from the thorax. Radiographs should show an angle
of 60–80° between the lateral border of the scapula and the medial border of the humerus.
With this angle, the active movement of the scapula will allow the arm abduction of 60–
80° while still allowing the contact with the thorax (Fig. 1). Anteposition should be 45°
which will permit an active anteposition of the arm of 65–75° as well as a vertical resting
position. Rotation must be such as to allow the hand to touch the abdomen, to reach the
mouth and to enter the lateral pocket of the trousers (25°) The above mentioned angles
may be slightly modified to suit the special needs of a patient.
There are numerous surgical techniques which differ in the surgical approach, the type
of fusion, the type of fixation and the type of bone graft (Fig. 2). Today, shoulder fusion
is generally done by intraarticular techniques but in unique cases with big loss of bone
the ancient extraarticular fusion techniques may still be used. It is mandatory to remove
both the cartilage and the subchondral cortical bone to obtain bleeding cancellous
surfaces to put in contact with each other. Fixation may be obtained in various ways:
multiple screws, plates of various types, external fixators or plasters. Bone grafts of
different types and sizes are added according to the needs of the case: solid
corticocancellous pieces taken from the iliac bone shaped according to the amount of
bone loss, corticocancellous chips or cancellous bone paste.
My preferred surgical approach is an angulated one, running above the spine of the
scapula and continuing onto the lateral aspect of the deltoid region. The deltoid muscle is
divided longitudinally and its insertion on the spine and clavicle partially detached. The
rotator cuff is also divided exposing the capsule which, in turn, is also opened and widely
removed to provide a wide operating field. The periosteum of the spine must be cut
longitudinally and retracted. This region is rich in vessels and the surgeon must proceed
with careful, progressive haemostasis. Then the head of the humerus is dislocated.
Decortication of both the humeral head and the glenoid is performed by chisels. At this
point the head of the humerus is pushed into the cavity of the glenoid. The arm is put in
the above mentioned position which is temporarily fixed by means of two long screws,
one from the humerus and one from the acromion. A long plate (12 or 14 holes) is bent
up to the desired angle and then secured to the spine of the scapula by means of five
screws and to the metadiaphysis of the humerus by means of four more (longer) screws
(Fig. 3).
To avoid excessive prominence of the plate under the skin, the acromion can be
partially removed, taking care to spare the acromioclavicular joint. It is advisable to add a
bony graft. My preferred method of grafting is to harvest cancel
Figure 2
(a) Arthrodesis of shoulder by means of screws and iliac
bone graft (posterior approach). (b) Fixation by means of
an external fixation. The joint has been decorticated with
addition of bone chips or bone ‘paste’. (c) Arthrodesis by
decortication of the bony heads, addition of cancellous
bone paste and fixation by means of a long bent plate and
screws.
Figure 3
Radiograph of a shoulder arthrodesis done by means of
plate and screws.
Figure 4
The cancellous bone taken from the proximal
metaepiphysis of the tibia is pounded to reduce it to a
‘paste’.
Figure 5
A good position of the shoulder arthrodesis allows the
patient both to reach the mouth and to hold something with
the thoracobrachial pliers.
lous bone from the proximal metaepiphysis of the tibia by means of a ‘curette’. The bone
is then pounded to obtain a ‘paste’ which is able to fill in all the recesses of the joint (Fig.
4). This paste is easily and quickly revascularized and revitalized as it has no cortical
bone (which requires creeping substitution).
Since 1963 I have performed 61 shoulder arthrodeses. I will discuss only the last 22
cases which have been operated on with the above described technique (the previous
cases were immobilized only by screws and plaster and resulted in some non-unions). In
the last 22 cases healing was obtained, on an average, in 4.5 months (range 3–8 months).
Evaluation is shown in Table 1. Sixteen of the cases could be classified as very good and
six as good. All of them acheived satisfactory final results and were able to do all daily
activities (Figs 5 and 6). I did not encounter pseudoarthrosis (which is the commonest
complication in series of other authors) but one case which was not fused at 7 months
was cured by a second operation—inserting a corticocancellous wedge graft into the
anterior opening of the joint. Nor did I encounter fractures of the humerus (another
common complication reported in literature): probably because of the modest abduction.
One case
Table 1 Evaluation of the results of shoulder fusion.

Abduction Fork to the Thoracobrachial Manual Daily
(active) mouth pliers work activity
Very 60° or more Yes Yes Yes Yes
good
Good 45°–60° Long fork Yes +/– Yes
Fair 30°–45° Very long Weak No +/–
fork
Poor 30° or less No No No No
Figure 6
20° of abduction allows both vertical position of the arm
(and the thoracobrachial pliers) and abduction to 70°.
healed in 7 months (delayed union). In two cases the plate led to decubitus ulcers of the
skin which were cured by local skin flaps. In three cases, after bone consolidation, I had
to remove the plate because it protruded under the skin in the acromion region. In two
more cases I had to remove two screws which were coming out. The position in internal
rotation obviously leads to a lack of external rotation and difficulty in reaching the back
of the neck but is very useful to access trousers’ pockets. Almost all the patients were not
able to sleep on the side of their fused shoulder. From the subjective point of view all the
patients were satisfied.
Elbow
Fusion of the elbow is more disabling than that of the shoulder because it is difficult to
fulfill or to compensate the requirements of this joint, i.e. enough extension to work,
enough flexion to eat and prono-supination. If the elbow is fused at an angle greater than
90° the hand will not reach the head nor get to the mouth with a spoon whereas if the
angle is smaller (70° or less) it will be difficult for the hand to reach distant objects on the
desk, to enter the pocket and so on. A compromise which is very useful, and I use in
elbow reimplantations, is fusing the elbow at an angle of 100° after shortening the
humerus so that even with this angle the mouth can be reached.
Indications for elbow fusion are as follows:
• open comminuted fractures
• reimplantations at elbow level
• surgical removal of bony heads (for various reasons)
• severe rheumatoid arthritis
• severe painful arthrosis
• infections.
The approach depends upon the traumatic wound or scar. If it is possible, a posteromedial
approach is preferred. The ulnar nerve must be atraumatically isolated and protected. In
recent wounds all the other structures must be simultaneously repaired. In case of
amputation– reimplantation the amount of shortening depends upon various factors: the
amount of crush and contamination, the necessity for suturing vessels and nerves without
tension and the functional needs of the patient (Fig. 7)
If the articular bony heads are widely resected the stumps are made up of cortical
compact bone which requires longer time to fuse and, therefore, some special techniques
or tricks should be used: one is to preserve and elevate wide flaps of periosteum to be
then sutured over the arthrodesis; another one is to put a sleeve of cancellous bone paste
around the bony heads and under the periosteal flaps. These techniques give firm and
quicker consolidation.
Figure 7
Arthrodesis of the elbow in case of amputation–
reimplantation at the level of the elbow.
Fixation may be obtained by means of a plate that allows at least three screws on the
humerus and three more on the ulna.
Depending on the presence or absence of prono-supinator muscles the head of the
radius may be resected or spared in order to allow pronosupination or the radius may be
involved in the fusion in a working position (mild pronation, 40°).
My series of elbow fusion is limited to only nine cases. All of them involved
reimplantation at elbow level. In general, amputations at this level are considered, by
many surgeons, a contraindication to reimplantation. On the contrary, my nine cases have
fairly good function of the hand and of the whole arm.
Wrist
The wrist joint may also benefit from arthrodesis either for traumatic or surgical loss of
bone or for any type of disease destroying the bony heads or making the joint painful or
paralytic (Dick 1982). In the past wrist fusion was very often used in poliomyelitis,
spastic palsies and tuberculosis.
In many cases, the choice can be between arthrodesis or another operation
(replacement, arthroplasty, first row resection, denervation) but in patients doing heavy
work or requiring a steady wrist, joint fusion remains the best option. When deciding to
do a wrist arthrodesis a further choice should be made between a radioulno-carpal or a
radio-carpal fusion (sparing the distal radio-ulnar joint or resecting the head of the ulna in
order to preserve prono-supination). Another option is between the fusion of the forearm
bone(s) with the first row or with the base of the metacarpals (second and third). By
fusing the radius with the first row (which is generally done only in wrist
reimplantations) some movement of the wrist in extension and flexion could theoretically
be preserved but this solution is generally discarded in other cases due to both the
degeneration or loss of the first row bones or to the secondary medio-carpal arthritis.
Hence when speaking of wrist arthrodesis, we refer to a radio-metacarpal fusion.
Indications for wrist fusion are as follows.
• destruction of the radio-carpal joint (posttraumatic or infectious) in patients whose
work involves heavy labour.
• reimplantation at the wrist level (Cannon and Urbaniak (2001)
• loss of bone (traumatic or iatrogenic (tumours))
• failure of joint replacement
• paralysis not likely to improve with tendon transfers
• spastic palsy with flexion deformity.
In the elderly patient with light occupation wrist replacement will be the first choice as
well for a rheumatoid wrist when stabilization methods are still useful. The main
contraindication is the young patient with an open epiphyseal plate in the distal radius.
The approach for a wrist fusion is mostly dorsal unless the traumatic wound allows
another approach. The lateral approach is also indicated especially if the ulna is spared
and can be used as a graft (Fig. 8a).
Most of the techniques use a corticocancellous graft taken from the ilium (Fig. 8b)
(Debeyre and Goutallier 1970). The graft I prefer is a corticocancellous stick advanced
from the dorsal aspect of the distal radius under a bridge and slipped under two splinters
elevated from the base of the 2nd and 3rd metacarpals with addition of cancellous bone
paste taken from the upper metaepiphysis of the tibia (Fig. 8c). Fixation is obtained by
means of there strong Kirschner wires: two in the fashion of St Andrew’s cross and one
transversally across the radius and the ulna (Fig. 8d). If a bone graft has to be taken from
elsewhere, in general, the donor site is the ilium. The bone graft can be inserted into a
trench dug in the radius and in the carpus or laid over the bones after having elevated on
both sides two lateral flaps taking the periosteum and the cortical surface of the bones. If
the loss of the bone is large the iliac graft should be bicortical and shaped according to
the needs (see Fig. 8a) (Larsons 1974, Field Herbert and Roner 1996). If the loss of the
radius is significant a free microvascular fibula graft may be used, putting the epiphysis
distally (Fig. 8d).
Figure 8
(a) Technique of removal of a bicortical cancellous graft
from ilium avoiding cosmetic defects. (b) Wrist arthrodesis
by medial approach. The distal ulna is removed,
decorticated and pushed (upside down) into a trench dug in
the radius, carpus and base of the 5th metacarpal. (c)
Arthrodesis of the wrist by means of the author’s own
method. A corticocancellous stick is slid from the dorsal
aspect of the distal radius (under a distal bone bridge) on
the decorticated bones of the carpus and pushed under two
bony flaps elevated from the bone of the 2nd and 3rd
metacarpal. Cancellous bone paste is added. Fixation is
obtained by means of three Kirschner wires (see text for
details). (d) Wrist arthrodesis by means of a vascularized
peroneal graft in case of big loss of bone—traumatic or
iatrogenic (tumour). (1) fibula; (2) the shaft of fibula
introduced into the radius; (3) periosteal flap of the fibula
sutured to the periosteum of radius; (4) end-to-side
anastomosis of the peroneal and radial artery; (5) addition
of cancellous bone paste.
Fixation varies depending on the surgeon’s preference. It can be done by:
• a plate and screws (modelled to the bony surface) (Fig. 9b)
• by one Rush rod with two or more staples (Fig. 9c)
• by external fixator
• by Kirschner wires.
All these methods of fixation (except the external fixation) are generally combined with
plaster immobilization for some weeks.
The position to be given to a wrist arthrodesis has been widely discussed. I have done
hundreds of goniometric measurements of the position of the wrist when at work or in
sports or when doing hobbies. These measurements have been made on photographs of
actors, sportsmen, politicians or heavy workers on numerous occasions. The result of
these measurements is that the main position, in any occasion, is 32° of extension and 15°
of ulnar deviation (Fig. 10). For certain jobs only or when both the wrists are to be fused,
one wrist can be arthrodesed in a slight flexion and supination for personal hygiene
activities.
Several complications are reported in literature, haematoma, infection, non-union,
reflex
Figure 9
Four different types of wrist arthrodesis. (a) Radio-carpal
fusion with Darrach procedure. (b) Radio-carpal fusion
with plate and screws preserving the prono-supination. (c)
Radio-carpal fusion with Rush rod and staples preserving
the prono-supination. (d) Radio-ulno-carpal fusion in
semipronation with sliding of a radial stick and three
Kirschner wires.
sympathetic dystrophy, carpal tunnel syndrome and distal ulnar impingement. I have
recently reviewed 18 cases (out of many operated over 50 years). Fourteen of them had
also had a Darrach procedure whereas four had radio-ulnocarpal fusion in working
position (i.e. 30° of extension, 15° of ulnar deviation and 60° of pronation). Five of them
were done for reimplantation at the wrist level. Regarding pain all of them where
satisfied with the result, having no pain on any occasion. Except for the reimplanted
patients, the other nine also had good strength and were able to do heavy work.
Figure 10
A careful research based on the measurement of the angles
of the wrist on photographs of hundreds of people (actors,
sportsmen, heavy workers, politicians) demonstrated that
the average working position is 32° of extension and 15°
of ulnar deviation.
References
Botteri G (1960) Arthrodesi. In: Mezzari A, ed. La Poliomielite. Napoli: Idelson, 197–9.
Brunelli GA (2001) Artrodesi o artroplastica del polso. In: Brunelli La Mano, Manuale di
Chirurgia. Micom: Milan, 390–4.
Brunelli GA (1972) Soft cancellous grafts for non-union and joint fusion, International
Congress of SICOT. Excerpta Medica, Amsterdam, 952–4.
Cannon DL, Urbaniak JR (2001) Transcarpal and radio carpal wrist amputation and
reimplantation, In: Watson HK, ed. The Wrist Lippincot Williams & Wilkins:
Weinzweig, 269–76.
Charnley J, Houston JK (1966) Compression arthrodesis of the shoulder, J Bone Joint
Surg 46B:614–20.
Debeyre J, Goutallier D (1970) L’artrodese du poignet par greffon iliaque intracarpien,
Presse Med 78:1993–4.
Dick HM (1982) Wrist and intercarpal arthrodesis. In: Green DP, ed. Operative Hand
Surgery. Churchill Livingstone: New York, 127–39.
Field Herbert T, Roner R (1996) Total wrist fusion: a functional assessment, J Hand Surg
(Br) 21:429–33.
Harryman II DT Walker EP, Harris SL et al (1993) Residual motion and function after
glenohumeral or scapulothoracic arthrodesis , J Shoulder Elbow Surg 2:275–85.
Hawkins RJ, Neer CS (1987) A functional analysis of shoulder fusions, Clin Orthop
223:65–76.
Johnson CA Okinaga S, Ochiai N et al (1986) External fixation of shoulder arthodesis,
Clin Orthop 211: 219–23.
Larsons S 1974 Compression arthrodesis of the wrist, Clin Orthop 99:146–53.
Nagano A Healy WL, Krackow KA et al (1989) Shoulder arthrodesis by external
fixation, Clin Orthop 247: 97–100.
Richards RR, Beaton D, Hudson AR (1963) Shoulder arthrodesis plate fixation:
functional outcome analysis, J Shoulder Elbow Surg 2:225–39.
Nerve defect repair
13
Nerve grafts
Michel Merle and Aymeric Lim
Repair of nerve defects by grafts was first attempted by Phillipeaux and Vulpian in 1870
and then by Albert (1876). However, later it was abandoned because of inconclusive
results. It was not until 1972 that Millesi validated the fascicular nerve grafting method of
repair by reporting good results (Millesi et al 1972). In 1974, the first vascularized nerve
graft performed by Taylor seemed to provide a solution for clinical situations with long
segmental losses and poorly vascularized beds unfavourable for the take of conventional
grafts (Taylor and Ham 1976). Over time, however, vascularized grafts have not proved
their superiority over conventional grafts and their early promise has not been borne out
due to the scarcity of suitable donor sites.
The reconstruction of long segment peripheral nerve defects or brachial plexus injuries
requires the use of long grafts. The difficulty in finding donor sites of sufficient length
motivated us to experiment with vascularized allografts in the rabbit (Bour and Merle
1989). Cyclosporine was used during the period of nerve regeneration. Stopping the
immunosuppressive treatment inevitably led to rejection of the graft. Mackinnon
preferred to use a method which involved pretreating the allografts to minimize rejection
after cessation of the immunosuppressive treatment (Mackinnon et al 1984). The first
allograft hand transplantations have shown that it is possible to recover sensory and
motor functions aided by a combination of immunosupressants. Among these, is
tacrolimus which, while promoting nerve regeneration, also unfortunately causes
neurotoxic side effects.
Lundborg first demonstrated that it is possible for a nerve to regenerate in a silicone
chamber (Lundborg and Hansson 1981). The concept of nerve tubes was further
developed by Restrepo et al (1985b), Madison et al (1988), Fields et al (1989),
Mackinnon and Dellon (1990a), and Archibald et al (1991). It is now accepted that an
artificial or biological tube is able to sustain nerve regeneration over a distance of less
than 15 mm.
Before the advances in microsurgical techniques led to the application of the principle
of direct primary suture, nerve grafting was considered to be the only option in the repair
of peripheral nerve lesions. Currently, no well conducted study has been able to prove
that nerve grafting, when possible, is superior to primary or secondary suture. Grafts are
thus indicated solely for the repair of nerve gaps.
Different types of graft
The choice of graft is important because it directly affects the results of the repair. The
repair of digital nerves requires similar sized nerve grafts harvested from the medial
antebrachial cutaneous nerve and more infrequently, vascularized grafts. For defects in
larger nerve trunks, sural nerve grafts are the most appropriate. A non-vascularized trunk
graft may be chosen when the decision has been made to sacrifice a major nerve. There
are problems with the vascularization of this volume of nerve tissue, however, and when
axonal regrowth occurs within the graft, it is often necrosed and sclerosed in its centre. It
is preferable to transform the nerve trunk into fascicles by intraneural dissection. Trunk
grafts are only indicated if vascularized. Strange (1947) was the first to propose the
concept of a two-stage repair of the median nerve with a vascularized ulnar nerve and
Taylor and Ham (1976) were the first to perform a free vascularized nerve graft using
microvascular sutures.
The concept of fascicular nerve grafting is impractical as, for the median nerve, it
would entail the use of one fascicle each for each of the 16–20 fascicles that compose the
nerve.
All our laboratory experience with nonvascularized and vascularized allografts has not
been applied clinically because of poor results. We have demonstrated that it is possible
to reestablish the continuity of a nerve over a short distance with an empty tube of
perineurium (Restrepo et al 1985b). For gaps of less than 15 mm, silicone,
polypropylene, collagen and polyglycolic acid tubes have been used. Despite numerous
appeals in favour of the role of tropism in this technique, we remain convinced that the
best method for nerve repair lies in the improvement of the technique of direct
coaptation.
Fascicular grafts
This is the most commonly used graft for the repair of nerve defects.
The choice of donor nerve
The sural nerve (Fig. 1)

We usually use this nerve. It is harvested from distal to proximal. A 6 cm retromalleolar
incision localizes the terminal two branches of division. A second transverse incision 16
cm proximal to the lateral malleolus (as described by Gilbert et al 1986) allows extraction
of the distal part of the sural nerve as well as identification of its junction with the
accessory sural nerve originating from the common peroneal nerve. Harvesting both
nerves is useful for large defects or the simultaneous repair of multiple nerves.
In young children, harvesting should be done via a single incision because of the
abundance of fatty tissue and fascia surrounding the nerve.
The medial antebrachial cutaneous nerve

For small defects of digital nerves, we prefer to harvest this nerve from the distal aspect
of the arm. An oblique incision is made from the hollow on the medial aspect of the
biceps tendon
Nerve grafts 169
Figure 1
Technique to harvest the lateral saphenous nerve and its
accessory branches. (a) The sural nerve arises from the
tibial nerve at the level of the popliteal fossa where the
superficial peroneal nerve also arises which takes its origin
on the common peroneal nerve and which travels
subcutaneously. (b) It is always necessary to perform an
additional incision at the junction of the top and middle
third in order to harvest both branches of the sural nerve.
to 5 cm proximal to the medial epicondyle. The basilic vein is retracted and anterior and
posterior branches of this nerve are exposed.
The lateral antebrachial cutaneous nerve

We have stopped using this nerve, the terminal branch of the musculocutaneous nerve, as
there is significant morbidity from scarring and loss of sensation at the donor site. It is a
donor nerve of last resort.
Technique
The technique of nerve grafting follows some general principles: the incision should be
some distance from the nerve; it should be extensile and allow excision of scar tissue; it
should allow transfer of healthy tissue to improve the vascularity of the bed; and finally,
it should permit the simultaneous repair of any major vessels.
There are two methods of grafting. The classically described method is that of Millesi
et al (1972), which involves the preparation of a fascicular group and the suture of every
fascicle within. The second technique, which we learned from Narakas, focuses on the
nerve trunk. A monobloc of fascicles with similar diameter to the nerve to be grafted is
assembled with tissue glue. The nerve should be resected until healthy nonindurated
tissue is obtained so as to minimize a fibroblastic reaction. Meyer’s instrumentation is
best for the secondary resection of a nerve.
The technique of Millesi (Fig. 2)

The nerves are resected until healthy tissue is obtained. Methylene blue applied to the
nerve
Figure 2
Fascicular graft according to Millesi. After a partial
epineurectomy and trimming of the fascicular groups, the
fascicular grafts are adjusted and sutured with 10/0 nylon.
ends then reveals the fascicular arrangement. Rarely monofascicular or oligofascicular

but most often polyfascicular, they are arranged in groups or independently. If the
organization is monofascicular or polyfascicular, multiple nerve segments are apposed to
the large diameter fascicle. In polyfascicular nerves, one graft is coapted to one fascicle.
Grafting of mono-or oligofascicular nerves does not necessitate intraneural dissection
or resection of the epineurium. For polyfascicular distributions, however, Millesi
recommends staggering the repair zones so as to avoid having all the coaptations in the
same plane. Although apparently logical, this method may be injurious to the nerve;
resecting the epineurium alters the blood supply and dissociating the fascicles increases
the risk of fibrosis and collagen invasion. Finally, staggered resection of fascicles can
only be done with curved scissors with consequent crushing of the nerve and a natural
evolution towards necrosis.
Nerve grafts 171
Each nerve segment is fixed with one or two sutures of Ethilon 9 or 10-0 while trying
to respect the correspondence between the proximal and distal nerve segments, which is
not always obvious.
We were very impressed with the time Millesi spent while performing a nerve grafting
operation, drawing with India ink on a sterile cardboard, the fascicular organization of
nerve ends separated by a few centimetres. Intraneural dissection can create the illusion
of fascicular correspondence over a certain distance. But the work
Figure 3
Fascicular nerve graft of the median nerve at the level of
the carpal tunnel.
of Sunderland (Sunderland 1945, Sunderland et al 1959) describing the changes in

direction in intraneural fascicular topography over 4–5 cm segments destroyed the
illusion that nervous anatomy could be accurately restored by grafting. On the other hand,
Jabaley et al (1980) demonstrated that, over a significant distance in the same quadrant,
were to be found the same fascicular groups linked by numerous ramifications.
In summary, it may be concluded that one should always try to restore the general
orientation of a nerve so that grafting may reflect the correspondence of the quadrants. To
look for a correlation at fascicular level remains an illusion. One must note that there are
certain levels at which it is possible to find a very marked fascicular organization; for
example the radial nerve at the elbow joint where one perceives a distinct organization of
the fascicles before actual division into posterior interosseous nerve and superficial
sensory branch. It is also the case for the ulnar nerve at the wrist where one finds
separation of the fascicular groups destined for the interossei and for the skin.
In these situations, the anatomy allows efficient interfascicular grafting; any
topographical error would send the motor nerves into cutaneous territory and vice versa.
The course of the graft is not necessarily the shortest between the two nervous
extremities. It is sometimes necessary to elongate the graft so as to place it in a healthy
bed favourable for its revascularization. Thus, when one would like to avoid returning via
the palmar approach to a multi-operated digit, it is possible to re-establish the continuity
of the digital nerve by placing the graft in a dorsolateral course with sutures in healthy
tissue. The length of the graft should be calculated by placing the operated limb or digit
in maximal extension so as to avoid all tension at the suture sites.
The technique of Narakas (Fig. 4)

This technique has the advantages of being simple, less invasive and fast whilst
respecting the major principles of reconstructive surgery.
Narakas resects the nerves out of the fibrotic zone with the aid of Victor Meyer
forceps. The nerve ends are stained with methylene blue and are primarily oriented using
the epineural vascularization as a guide and secondarily the fascicu
Figure 4
Fascicular graft according to Narakas. (a) The nerve defect
is measured by extending the neighbouring joints. (b) The
sural nerve graft cleaned from its connective tissue is fitted
so as to have the same diameter as that of the nerve to be
grafted; they are joined at each end with Tissucol. (c)
Trimming of the nerve graft is performed with a
‘guillotine’ clamp of V. Meyer. (d) The graft is jointed to
the nerve stumps with Tissucol.
lar distribution if the defect is only of a few centimetres. The gap is measured carefully
with the limb in maximal extension and recognizing that this distance is always longer
than the real nerve loss, 1–2 cm are added depending on the course of the graft.
The sural and, if necessary, the accessory sural nerve are harvested with multiple stab
incisions and then cleaned under the microscope of all fat and connective tissue leaving
only two or three fascicular groups. The sural nerve is then laid out on a block of
polyethylene and folded on itself until the aggregate diameter approximates that of the
nerve to be grafted. The ends are bunched together like a bundle of firewood, glued with
Tissucol (Baxter, USA) and trimmed with Victor Meyer forceps. The middle of the graft
is left free for the nerve segments to spread in the bed.
This technique avoids all intraneural dissection. Glue replaces suture material which
always causes a foreign body reaction. The graft also has the advantage of being ‘made to
measure’. It is, however, less precise with respect to fascicular groups and some nerve
segments may be wasted by coaptation with non-neuronal epineural tissue (Fig. 5). We
have used this technique satisfactorily since 1987. Our results are comparable with those
of Millesi with the added advantage of simplicity of technique. The use of glue does not
impose a barrier to nervous regeneration (Merle 1992).
Nerve grafts 173
Figure 5
Ulnar nerve graft at the level of the wrist. (a) The nerve is
trimmed to a healthy area using the V. Meyer clamp. (b)
The sural nerve is fitted as the same diameter as the ulnar
nerve. (c) Both extremities of the nerve graft are glued
with Tissucol. (d) Trimming of the nerve graft using
freezing technique. (e) Gluing of the nerve graft to the
ulnar nerve using Tissucol.
Postoperative care
All grafts must be immobilized postoperatively. When the length of the grafts has been
calculated with the wrist in mild extension, it suffices to immobilize the wrist in that
position for 3 weeks. For digital nerves, the metacarpophalangeal joints are immobilized
in 60° flexion for 3 weeks while allowing early mobilization of the proximal and distal
interphalangeal joints.
Indications
Grafts are indicated in all nerve defects which cannot be repaired directly without tension
despite the methods of mobilization, transposition and bone shortening. The natural
separation of a nerve after section is linked to its elasticity. This can range from 1 cm to 2
cm for a lesion at the wrist to 5 cm at the level of the arm. Mobilization of the nerve by
extensive dissection with mild flexion of the wrist allows primary repair in most cases. If,
however, the resection of a neuroma creates a gap of 4 cm or more in the wrist or the
forearm, grafting is indicated.
Narakas’ technique is the simplest and one must not hesitate to elongate the graft so to
as to allow a course in a healthier bed.
Results
Grafting of nerve defects is reserved for the most severe injuries. This explains the
mediocrity of our results (Dumontier et al 1990). Despite the introduction of
microsurgical techniques, in 10 years we have not observed any significant improvement
in useful results which have ranged from 23% to 25%. We find ourselves in conflict with
the multicentric study performed by Frykman and Gramyk (1991) who observed 81%
useful motor results and 79% useful sensory results after grafting. Superior to the best
results of primary repair, these figures are difficult to understand, especially given all the
known problems with grafting. It is, however possible that many of their patients may
have benefited from direct repair if they had been subject to our indications. Finally, the
superiority of their results may be due in part to the young age of the patients—less than
20 years old in 45% of the cases. We have demonstrated that after primary repair, useful
results were found in 88% of patients less than 10 years old (Merle et al 1984).
The accurate evaluation of results demands specificity for each nerve. The functional
result of the ulnar nerve needs to take into account the strength of grip, while useful
results for a median nerve would essentially reflect the return of sensory function. The
age of the patient, the nature of the injury and associated lesions are determinant factors
in the prognosis.
Vascularized nerve grafts
History (Table 1)
Large nerve defects, i.e. more 10 cm, have an uncertain outcome when they are repaired
by conventional fascicular free grafting techniques. Therefore, Taylor aroused great
interest when he described the use of a radial nerve to graft an extensive loss of substance
in a median nerve lesion (Taylor and Ham 1976). During the following decade, many
experimental studies were undertaken and this new technique was applied
Nerve grafts 175
Table 1 Review of vascularized graft techniques.

Authors Year Technique
Reconstruction of the median by the pedicled ulnar in
Strange 1947
two procedures
Reconstruction of the tibial nerve by the pedicled
McCarty 1951
peroneal nerve
Taylor and Ham 1976 Superficial radial to median
Bonney et al 1984 Ulnar nerve in the forearm
Townsend and Sural nerve with its arterialized vein
1978
Taylor
Fachinelli et al 1981 Sural nerve and superficial sural artery
Comtet et al 1981 Medial cutaneous nerve
Ulnar nerve in the arm and proximal ulnar collateral
Lebreton et al 1983
artery
Oberlin et al 1985 Pedicled common peroneal nerve
Internal branch of the anterior tibial nerve and dorsalis
Rose 1985
pedis
Anterior interosseous nerve and anterior interosseous
Merle and Dautel 1991
artery
clinically. However, with the lack of suitable donor sites and results that did not appear to
be better than those with conventional grafts, enthusiasm and interest subsided.
The principle of the vascularized nerve graft goes back to Strange who described the
possibility of grafting the median nerve by staged transposition of the ulnar nerve; he
obtained his first success in 1948 (Strange 1947, 1948). The same principle of pedicled
grafting was applied by McCarty to repair the tibial nerve (McCarty 1951).
Microsurgery revived interest in the technique of nerve repair by vascularized
grafting. Taylor used the superficial branch of the radial nerve, 24 cm long, vascularized
by the radial artery to repair a defect of the median nerve. This technique is acceptable in
patients presenting multiple trauma of the limbs, because sequelae at the donor site are
minimal. However, the sensory loss would be unacceptable in the patient presenting with
only a single injury.
Taylor (1978) classified vascularization of peripheral nerves into five types—the first
three of which could be used for free vascularized transfers (Fig. 6). Taylor’s work in the
field of donor sites was taken up by others. Bonney et al (1977) suggested use of the
antebrachial portion of the ulnar nerve. Comtet et al (1981) described the vascularization
of the internal cutaneous nerve and Fachinelli et al (1981) described the superficial sural
artery which vascularizes the sural nerve. Lebreton et al (1983) described the
vascularization of the ulnar nerve in the arm and Oberlin and Alnot (1985) described the
pedicled common peroneal nerve. Rose (1985) repaired digital nerve defects using the
internal branch of the deep peroneal nerve lifted with the dorsalis pedis artery: later, he
came to use only a vena comitans which he arterialized. This arterialization technique
was described by Townsend and Taylor (1984) for the sural nerve and was also
developed by Gu et al (1985). Recently, Dautel used the anterior interosseous nerve taken
with the anterior interosseous artery (Merle and Dautel 1991).
Our clinical experience summarizes the problems encountered in the upper limb, i.e.
avulsions of the brachial plexus, extensive loss of substance with poor tissue environment
(Volkmann, crush) and defects of digital nerves.
Vascularized grafts for extensive loss of substance of the brachial plexus

In cases of intraspinal avulsion of C8 and T1 roots, it is legitimate to use the brachial or
antebrachial portion of the ulnar nerve to bridge an extensive gap, from C5/C6 to the
upper trunk or even to the posterior cord.
We used the brachial portion of the ulnar nerve in five cases, five times as a free
vascularized transfer and four times as a pedicled graft. By the use of free vascularized
grafts measuring about 16.5 cm, it was possible to bridge gaps averaging 14.4 cm in
length. Usually, vascular anastomoses
Figure 6
Five types of vascularization of peripheral nerve described
by I. Taylor. Types a, b, c, could be used for free
vascularized transfers.
of the proximal ulnar pedicle were made with one of the cervical or thoracic branches of
the subclavian artery.
Four out of the five vascularized transfers remained viable. The Tinel sign progressed
distally at an average of 3 mm per day in the first 6 months after operation. Contractions
of the biceps were first observed clinically and electromyographically in the ninth month
after operation whereas the same result would be observed 12 months after non-
vascularized fascicular grafts. The one observed failure was caused by early thrombosis
of the arterial and venous anastomoses and since extrinsic neovascularization of whole
nerve trunk grafts is poor or delayed, the grafted nerve underwent ischaemic necrosis.
Functional failure was complete in this case.
In the four cases where we used the pedicled brachial segment of the ulnar nerve, we
observed recovery of the biceps graded M3+ (three patients) and M4 (one patient). In this
Nerve grafts 177
situation, there is no risk of thrombosis but the length of the graft is a major concern. It is
imperative to dissect the ulnar nerve as far as 6 cm distal to the medial epicondyle of the
humerus. This is necessary in order to mobilize the ulnar nerve upwards and suture it to
the C5 or C6 root without tension.
In this short series, it is worth noting the consistency of results of biceps function
when the vascular anastomoses remain patent. Yet, when the patients were examined
after 3 years or more, functional results were no better than those obtained with
successful conventional fascicular grafts; progress of the Tinel sign, which occurred
through the vascularized graft at above average speed during the first 6 months (3 mm
per day), later stabilized at 1.5 mm per day.
Our results were similar to those obtained by Bonney et al (1984) (two failures out of
12 cases), and Alnot (1988, one failure out of 10), who used the ulnar nerve with its
artery. We avoided using the antebrachial portion of the ulnar nerve so as not to sacrifice
the dominant artery of the hand.
Vascularized nerve grafts for extensive loss of nerve substance in the

forearm
Severe trauma of the forearm (crush and avulsion injuries, Volkmann’s contracture)
necessitate the restoration of at least sensory function of the median nerve. The tissue
environment is usually poor and cannot support free fascicular grafts. Grafting the
median nerve with the vascularized brachial segment of the ulnar nerve seems to be a
good choice (Fig. 7).
We have used this technique on three occasions, two of these for Volkmannn’s
ischaemic contracture. The first two cases failed: early thrombosis of the vascular
anastomoses resulted in necrosis of the grafts and no functional recovery was observed.
This emphasizes the uncertainty of microsurgical techniques applied to
Figure 7
Ulnar vascularized nerve graft to repair median nerve at
the level of the wrist. (a) Sequelae from a median and an
ulnar nerve injury in a 60-year-old patient. Total
anaesthesia of the hand. (b) Design of the free compound
flap: the skin flap is vascularized by its ulnar artery which
also vascularized the ulnar nerve. (c) The free compound
flap. (d) Result after 1 year, protective sensitivity has
returned in the territory of the median nerve.
recipient vessels severely damaged by the initial trauma.
Grafts of digital nerve

The published results of conventional digital nerve grafts vary widely. One can only
admire the results of Mackinnon and Delton (1988) who reported 31 cases of
discriminating sensitivity out of 33 operations, i.e. a 93% success rate. Tenny and Lewis
(1984) obtained discriminating sensitivity in 32 cases out of 42. In our experience,
Dumontier et al (1990) observed discriminating sensitivity in three out of 16 patients.
These disappointing results led us to investigate vascularized grafts. At first, we used
Rose’s (1985) technique: the internal branch of the deep peroneal nerve is harvested with
a vena comitans that is used to bridge the digital artery. Later, we switched to the
technique of Dautel using the anterior interosseous nerve and its artery (Merle and Dautel
1991). Our prospective study included nine patients. The average length of the graft was
35 mm. In the first five cases, the donor site used was the one described by Rose, i.e. the
internal branch of the deep peroneal nerve and the vena comitans adjacent to the dorsalis
pedis artery. In the last four cases, the segment of the anterior interosseous nerve distal to
the origin of the flexor pollicis longus nerve was used as a donor site. The vascular
anastomoses were end-to-end except in two cases where the proximal anastomosis was an
end-toside suture. Immediate patency was judged at tourniquet release with a patency test
done distal to both proximal and distal vascular anastomoses. All our grafts were found to
be patent. No further monitoring was done in the first days after operation.
Long-term vascular results were assessed using Allen’ test; in the first six cases, the
results of the test were compared with arteriographic data obtained in the third month
after operation. Since the results were consistently concurrent, no arteriography was done
in the last three cases. Thrombosis was observed in six of the grafts at the time of control;
out of the three remaining patent grafts, two were those cases where the proximal
vascular anastomosis was end-to-side. Assessment of sensory results was done with the
static and dynamic two-point discrimination tests. No selective block of the healthy
contralateral nerve was used to study the sensory result. However, care was taken to test
precisely the area of the pulp that was innervated solely by the grafted nerve. Sensory
results observed in these nine clinical cases were as follows: three cases were considered
failures since static discrimination was equal to, or worse than, 15 mm. No patient had a
static two-point discrimination better than 10 mm. Even though this series was too small
for statistical analysis, it seems that long-term sensation was not influenced by graft
patency.
The vascular results obtained in this series demonstrated the difficulties of late
reconstruction of digital vascular axes when the contralateral axis is patent. Since there
was no long-term postoperative monitoring, the exact time at which thrombosis occurred
is not known. The sensory results of the six cases with long-term thrombosis were not
different from those of the three cases where vessels remained patent. Thus, there is an
important difference between vascularized nerve graft involving small nerves, such as
digital nerves, and those involving large nerve trunks. When secondary thrombosis
occurs, small calibre nerves, such as the internal branch of the deep peroneal nerve or the
anterior interosseous nerve, are probably revascularized from their tissue environment as
Nerve grafts 179
conventional non-vascularized nerve grafts would be. Our results are not in agreement
with those of Rose et al (1989).
Discussion
Our clinical experience of vascularized grafts indicates that the results, i.e. sensory and
motor functional recovery, were not significantly enhanced. This was true for both the
brachial portion of the ulnar nerve and small nerve trunks. The only guaranteed benefit,
observed in cases of brachial plexus lesion, was the consistent recovery of biceps
function at M3+ or M4 when the graft remained patent. However, when there was
thrombosis of the anastomosis, necrosis of the graft ensued and functional failure was
complete. This risk is not negligible in surgery of the brachial plexus and must be
weighed against the relative safety of conventional fascicular grafts.
The experimental work of Daly and Wood (1985) and of Lux et al (1988) on the dog,
demonstrated that blood supply of conventional nonvascularized grafts was superior to
that of vascularized grafts on day 4 to day 6, provided the tissue bed was healthy. This is
the case with brachial plexus lesions, where the tissue bed is usually satisfactory and
conducive to revascularization of free nerve grafts.
Claims of superiority of vascularized nerve grafts have been based mostly on
optimistic forecasts during the first month after operation, when the Tinel sign progresses
through the graft at a rate of 3 mm per day. This may be due to rapid phagocytosis of
myelin sheaths and enhanced activity of Schwann cells. The fact remains that
vascularized grafts have less tendency to sclerose than conventional grafts. The latter are
subjected to ischaemia for several days; although Penkert et al (1988) have shown that
rabbit Schwann cells can survive ischaemia for 6–7 days, there is little doubt that the
ischaemia hinders Schwann cell activity.
Axonal regrowth seems to be optimal in the vascularized graft. However, at the
proximal and distal suture sites and when the nerve divides into collateral branches,
axonal sprouts meet with the same obstacles as in conventional grafts. This may explain
why the final results are similar with both techniques.
These clinical results are not as good as the results of animal experimentation.
Restrepo et al (1985a), and Shibata et al (1988) demonstrated in the rabbit that the
number and diameter of fibres, along with the thickness of myelin sheaths, were greater
in vascularized than in non-vascularized grafts. Pho et al (1985) found no histological
difference between vascularized and non-vascularized grafts in the rat. All donor sites are
not equally good. The trunk of the ulnar nerve is better because it has both arterial supply
and venous return. This is not the case with grafts of the internal branch of the deep
peroneal nerve or of the anterior interosseous nerve, where a vena comitans is arterialized
but no venous return is reconstructed. In these conditions, the nerve cannot be considered
to be physiologically vascularized. It is probable that the nerve soon suffers from venous
stasis, leading to oedema or even thrombosis. This insufficiency of venous return
probably explains the disappointing sensory results we have observed after grafting
digital nerves with Rose’s technique. The donor sites that we have listed in Table 1 are
few in number.
Even when nerves are of sufficient diameter and vessels are of appropriate calibre,
these sites are rarely useful; the avulsions of C8 and T1 roots that justify their use are not
a frequent occurrence.
The technical obstacles might be overcome in the future: at present, they restrict the
surgeon’s choices. We prefer to ameliorate the quality of the tissue bed rather than to
continue transplanting rare vascularized grafts. Giving a new surface to sclerosed tissue
beds through the use of free or pedicled flaps will guarantee rapid revascularization of
conventional fascicular grafts. This option is all the more justifiable in cases of complex
trauma; the associated procedures on bone and tendons also benefit from a satisfactory
tissue bed.
Nerve allografts
The successful experience of immunosuppressive treatment for heart, renal, liver and
now hand transplants along with extensive experimental evidence encouraged the use of
nerve allografts. Freezing grafts and adjuvant immunosuppressants allow application of
these techniques in humans but there are unresolved technical and ethical problems,
which have limited clinical usage to the present time.
History
The concept of nerve allografts is not new and it is interesting to note that the clinical
case done by Albert in 1885 preceded by 5 years the work of Forsmann (1898) who
performed a ‘successful’ allograft in a rabbit. This was followed by numerous
experimental works until 1945, on dogs, cats and monkeys with results ranging from
failure to success. After a gap of 20 years subsequent work by Dos Gupta et al (1967),
Zalewski (1971), Pollard and Fitzpatrick (1973), Chung and Chung (1974), Comtet and
Revillard (1979) and Levinthal et al (1978) between 1967 and 1981 showed constant
failure in the rat and pig.
From 1982 onwards, Mackinnon et al (1984), Bain et al (1987), Evans et al (1994) and
others demonstrated that nerve allografts in the mouse only work if they are refrigerated
in Belzer’s solution (University of Wisconsin Cold Storage Solution, Evans et al 1999)
for a minimum of 7 days with small doses of cyclosporin A. They also proved that the
immunosuppressive effect of monoclonal antibodies prevented rejection of the graft and
allowed good regeneration of the nerve (Nakao et al 1995). Experimental work was also
done in the rabbit and the rat to determine the feasibility of vascularized allografts (Best
et al 1993). We evaluated brachial plexus repair in the rabbit and the dog with massive
vascularized allograft. These grafts, which were only preserved for a few hours in
Ringer’s solution before revascularization, did not undergo any refrigeration. The rabbits
were then treated with cyclosporin A and signs of regeneration were obvious during
immunosuppressive therapy, however when the treatment was stopped all the rabbits
developed a massive rejection reaction with loss of function (Bour and Merle 1989). Best
et al (1993) compared vascularized autograft and vascularized allograft with and without
immunosuppressive therapy in the rat. They proved that vascularized allograft gave
equivalent results when compared to vascularized autograft. On the other hand,
Nerve grafts 181
vascularized allograft without immunosuppression was subject to an acute and massive

rejection, with vascular thrombosis possibly accelerated by direct contact with recipient
antibodies. Concurrently, we have developed the clinical use of vascularized autografts.
However, we realized after a few years follow-up that the functional results were not
superior to conventional non-vascularized autografts when the surrounding tissue bed
was healthy permitting revascularization of the grafts. The clinical results of vascularized
autografts have not been remarkable, which explains the small number of studies on this
topic (Merle and Dautel 1991).
Experimental data in favour of non-vascularized allografts

Numerous studies, mostly on the rat, rabbit and goat, have demonstrated the value of
graft pretreatment with and adjuvant immunosuppressive treatment with or without
monoclonal antibodies.
Pretreatment of grafts
Preservation at 5°C in Belzer’s solution (University of Wisconsin Cold Storage Solution,
Evans et al 1999) for a period of 7 days does not diminish the number of Schwann cells
but reduces the immunogenicity. Lower doses of cyclosporin are thus required
(Mackinnon et al 1992). This period of preservation allows the recipient to be
progressively immunosuppressed, making allograft nerve grafting an elective operation
unlike other allograft procedures. In addition, the number of myelinated fibres during
regeneration and the conduction velocity are increased. This effect is particularly evident
when FK 506 (tacrolimus) is used as the immunosuppressor. Injection of recipient
Schwann cells into the allograft also contributes to the protection of the graft from
rejection.
Immunosuppressive treatments
The benefits of immunosuppression with cyclosporin A have been well demonstrated in
the rat (Bain et al 1987, Mackinnon et al 1992, Strasberg et al 1996). The allograft allows
axonal regeneration in the host to proceed. The number of donor Schwann cells
diminishes while the recipient Schwann cells colonize the allograft. Without
immunosuppression however the rejection reaction is very rapid and the allograft
becomes a fibrous cord obstructing any nerve regeneration.
Atchabahian et al (1998) have demonstrated that immunosuppression can be stopped
without detriment to neurological function as long as nerve regeneration has reached the
sensory and motor end organs. Generally, at this stage, recipient Schwan cells have
finished colonizing the allograft. Cases of rejection have to be detected early so as to
reinforce the immunosuppressive treatment. It is possible to salvage an allograft which is
being rejected if FK 506 is added within 15 days (Feng et al 2001).
Monoclonal antibodies
The usefulness of monoclonal antibodies in antirejection therapy for organ
transplantation has been well demonstrated. In the rat, different combinations have been
shown to protect the allograft from rejection while permitting a decrease in the dose of
cyclosporin A. This is the case for ICAM-1, LFA-1 (Nakao et al 1995) and CD4
(RIB502) (Doolabh and Mackinnon 1999). They are thus useful when there are adverse
effects from the immunosuppressive therapy, allowing a decrease in dose while
protecting the graft.
FK 506 (tacrolimus) and nerve regeneration

Lyons et al (1994) showed that in cell cultures, FK 506 increases the rate of axonal
growth. Since then, numerous studies have confirmed this capability. It has also been
reported that weak doses of FK 506 on treated allografts allow better functional results in
allografts than in autografts (Doolabh et al 1999).
The accumulation of all this experimental data encouraged clinicians to apply the
technique of non-vascularized allografts in humans.
Mackinnon’s clinical series (Mackinnon et al 2001)

Mackinnon successfully performed the first case in June 1988; a sciatic nerve to posterior
tibial nerve defect in an 11-year-old boy was repaired using a 10-strand allograft 23 cm
long. After 2 years and 2 months of immunosuppressive treatment (cyclosporin A), the
patient recovered some sensation but no useful motor function. Between 1988 and 1998,
Mackinnon carried out seven allografts on four women and three men for the following
indications: three severe median nerve defects, two associated with ulnar nerve defects;
one radial nerve defect; one sciatic nerve defect and two posterior tibial nerve defects. To
facilitate revascularization of the allografts, the nerves were stripped into fascicular
groups and all fat was removed. They were also placed under the skin to monitor better
for rejection.
The mean age of the subjects was 15 years. The mean length of the allografts was 190
cm. In the first two patients only allograft nerve was used for repair, while the five
subsequent patients also benefited from autograft sural nerve.
The mean time of immunosuppression was 18 months. Five patients were treated with
cyclosporin A and two with FK 506. Immunosuppression was stopped 6 months after the
Tinel sign was detected distal to the allograft with objective signs of return of sensation
and muscular function. The immunosuppressive treatment was as follows:
• cyclosporin A 200–300 ng/ml or FK 506 5–15 ng/ml
• azathioprine 1–1.5 mg/kg/day
• prednisolone 0.25–0.5 mg/kg/day for 5–8 weeks.
One graft was rejected after 4 months. The rejection reaction did not however affect the
autograft which was partially grafting the ulnar nerve. Long-term follow-up verified a
return of protective sensibility in six patients, with a two-point discrimination of 3 mm in
Nerve grafts 183
one patient who had grafting of the ulnar nerve. There was useful motor recovery in three
cases.
Discussion
Currently, the technique used by all microsurgical teams for repairing nerve defects is
interfascicular autografting. Useful functional results, however, rarely occur in more than
60% of the patients in any series (Millesi et al 1972). Though vascularized autografts
have been useful in large defects, their use is limited by the donor site morbidity and the
fact that the functional results are not significantly superior to conventional fascicular
autografts (Merle and Dautel 1991).
Indications for nerve allografts do exist as shown in Mackinnon’s series (2001); in 10
years, she found 10 suitable cases but only seven were operated upon. While the sensory
results are encouraging, the motor recovery has been poor but one should note that most
of the limbs involved in this series were destined for a total amputation. There are many
arguments in favour of allografts; they are certainly an elegant solution for grafting large
nerve defects. The problems associated with the immunosuppressive treatment are in part
resolved by the limited duration of 18 months on average. Rejection reactions, which do
not affect the concurrently placed autografts, are monitored better by placing the grafts
subcutaneously. Nervous regeneration definitely benefits from FK 506 (tacrolimus)
(Lyons et al 1994). The main disadvantage is the risk of infection with viruses or even
prions. Is it ethical to subject a patient to these risks in the hope of obtaining a purely
functional benefit? Long-term follow-up and a detailed analysis of the secondary effects
of the immunosuppressive drugs would clear any ambiguity about their use.
Even if Mackinnon’s experience is unique, she had the great merit of basing her work
on a large body of experimental work, systematically resolving all the problems
encountered between 1967 and 1981. She was able to overcome them by cold treatment
of the grafts for 7 days at 5°C. It was also with better immunosuppression protocols and
in particular the addition of FK 506 that the first clinical cases were possible.
The caution observed by microsurgical teams with regard to allografts will diminish
when the principles of allograft nerve regeneration are better known, the adverse effects
of immunosuppressive therapy are diminished and the risks of viral or prion infection are
addressed.
Nerve tubes
Lundborg’s work using silicone artificial regeneration chambers demonstrates the role of
trophism for nerve fibre regeneration (Lundborg and Hansson 1981). The silicone
chamber was also an excellent experimental tool for the evaluation of the maximal gap
that a nerve can bridge when both ends are fixed to such a tube. The concept of a
neurotube, a substitute for autografts, had already been proposed by Weiss in 1943. With
Restrepo, we evaluated in the rabbit the use of an empty perineural tube to successfully
repair sciatic nerve defects of 15 mm. These results had been confirmed in humans with
the repair of digital nerve defects (Restrepo et al 1985b). Since then, numerous
biomaterials have been used to make a neurotube. Dellon and Mackinnon proposed a
polyglycolic acid tube then evolved to trimethylene glycolide carbonate (Maxon) and
finally experimented with collagen (Mackinnon and Dellon 1990b).
All these experimental studies demonstrated the capacity of the nerve to regenerate if
the gap is between 5 mm and 15 mm. Reported complications range from kinking to
complete rejection while observing excessive foreign body reactions when the absorbable
biomaterial used is polyglycolic acid. Merle et al (1989) have described a chronic neuritis
resulting from a fibrous sleeve formed within a silicone tube causing ischaemia to the
nerve. Lundborg has rejected this type of complication and justifies its use in humans by
reporting the success obtained in seven patients with median or ulnar nerve defects of 3–5
mm (Dahlin et al 2001). Archibald et al (1995) have proposed the utilization of collagen
tubes. The results obtained in eight monkeys in which a gap of 5 mm in 15 median nerves
and 1 ulnar nerve were repaired with such a tube have demonstrated a functional result
equivalent to conventional grafting or direct suture.
Other teams have looked for resorbable materials with low inflammatory potential.
Using a tube made out of poly-3-hydroxybutyrate (PHB), Young et al (2002) reported
nerve regeneration in a rabbit over a distance of 4 cm. The use of a vein filled with
muscle (Fornaro et al 2001) encourages the migration of Schwann cells, the indispensable
guide to nerve regeneration. The work published by the Italian team of Battiston confirms
other similar works. The clinical application has been disappointing as the vein tends to
fibrose and sometimes becomes totally obstructed. The bed that hosts this composite graft
(vein and muscle) has to very good to support its revascularization. The accumulation of
numerous experimental works confirms that nerve regeneration in a ‘neurotube’ is
possible over a distance of 5–15 mm. It is enhanced by using an inert material and a tube
cavity that facilitates the migration of Schwann cells. The integration, within the tube of
Schwann cells, of ‘nerve growth factor’ and of resorbable filaments would probably
improve this concept.
Conclusions
The solution for the repair of nerve defects has not been found despite the multiple
therapeutic options. The fascicular autograft remains the best technique in most cases.
Vascularized nerve grafts have been disappointing and they should be reserved for use
only in cases involving very large defects and when the recipient bed is of poor quality
(crush injuries, Volkmann’s ischaemic contractures).
It has not been proved that allografts with an immunosuppressive treatment that is
stopped after reinnervation can provide a useful functional result for the patient. In
addition, the ethics of using immunosuppressive drugs for a purely functional gain is
questionable.
For gaps of less than 15 mm, the utilization of a neurotube is justifiable but only time
will tell if it is better to use a biotube made with the patient’s own tissues or a tube
manufactured with resorbable materials and sown with Schwann cells and filled with
growth factor.
Nerve grafts 185
References
Albert E (1885) Eirige operationen au nerven, Wien Med Presse 26:1285.

Alnot JY (1988) The use of ulnar nerve as a vascularised nerve graft in some peculiar
conditions and particularly in total palsies of the brachial plexus C7, C8, D1 avulsions.
In: Brunelli G, ed. Textbook of Microsurgery. Masson: Milan, 637–9.
Archibald SJ, Shefner J, Krarup C, Madison RD (1995) Monkey median nerve repaired
by nerve graft or collagen nerve guide tube, J Neurosci 15:4109–23.
Atchabahian A, Mackinnon SE, Doolabh VB, Yu S, Hunter DA, Fly MW (1998)
Indefinite survival of peripheral nerve allografts after temporary cyclosporin A
immunosuppression. Res Neurol Neurosci 13:129.
Bain JR, Mackinnon SE, Hudson AR, Falk RE, Hunter DA (1987) Evaluation of nerve
regeneration across nerve allografts in rats immunosuppressed with cyclosporin A,
Surg Forum 38:515–17.
Best TJ, Mackinnon SE, Bain JR, Makino A, Evans JE (1993) Verification of a free
vascularized nerve graft model in the rat with application to the peripheral nerve
allograft, Plast Reconstr Surg 92:516–25.
Bonney G, Birch R, Jamieson AM, Eames RA (1984) Experience with vascularized
nerve grafts, Clin Plast Surg 11:137–42.
Bour C, Merle M (1989) Les allogreffes nerveuses et les problèmes immunologiques,
Ann Chir Main 8:334–5.
Chung PKC, Chung SKY (1974) Evaluation of Imuran and Locke’s solution in peripheral
nerve homografts, Exp Neurol 42:41.
Comtet JJ, Revillard JP (1979) Peripheral nerve allografts. Distinctive histological
features of nerves degeneration and immunological rejection, Transplantation 28:103.
Comtet JJ, Bertrand HG, Moyen B, Condamine JL (1981) Greffe nerveuse vascularisée
utilisant le branchial cutané interne transplanté avec un pédicule vasculaire. Lyon Chir
77:62–3.
Dahlin LB, Anagnostaki L, Lundborg G (2001) Tissue response to silicone tubes used to
repair human median and ulnar nerves, Scand J Plast Reconstr Hand Surg 35:29–34.
Daly PJ, Wood MB (1985) Endoneural and epineural blood flow evaluation with free
vascularized and conventional nerve grafts in the canine, J Reconstr Microsurg 2:45–
9.
Doolabh VB, Mackinnon SE (1999) FK 506 accelerates functional recovery following
nerve grafting in a rat model, Plast Reconstr Surg 103:1928.
Doolabh VB, Motoyama K, Mackinnon SE, Flye MW (1998) Long term tolerance to
peripheral nerve allografts with donor antigen and anti-CD4 monoclonal antibody
(RIB 5/2) pretreatment, Ann Coll Surg Forum 49:633.
Dos Gupta TK (1967) Mechanism of rejection of peripheral nerve allografts, Surg
Gynecol Obstet 125: 1058–68.
Dumontier C, Kloos M, Dap F, Merle M (1990) Greffes nerveuses des collatéraux
digitaux. A propos d’une serie de 16 cas revus, Rev Chir Orthop 76:311–16.
Evans PJ, Midha R, Mackinnon SE (1994) The peripheral nerve allograft: a

comprehensive review of regeneration and neuroimmunology. Prog Neurobiol
43:187–233.
Evans PJ, Mackinnon SE, Midha R et al (1999) Regeneration across cold preserved
peripheral nerve allografts, Microsurgery 19:115–27.
Fachinelli A, Masquelet AC, Restrepo Y, Gilbert A (1981) The vascularized sural nerve,
Int J Microsurgery 3:57–62.
Feng FY, Ogden MA, Myckatyn TM et al (2001) FK 506 rescues peripheral nerve
allografts in acute rejection, J Neurotrauma 18:217.
Fields RD, Le Beau JM, Longo FM, Ellisman MH (1989) Nerve regeneration through
artificial tubular implants, Prog Neurobiol 33:87–134.
Fornaro M, Tos P, Geuna S, Giacobini-Robecchi MG, Battiston B (2001) Confocal
imaging of Schwann-cell migration along muscle-vein combined grafts used, to bridge
nerve defects in the rat, Microsurgery 21:153–5.
Forssman J (1898) Uber den uraschen, welche die wachstrums richtung der peripheren
nerven fasern beider regeneration bestimmern, Biet Path Anat, 24:56.
Frykman GK, Gramik K (1991) Results of nerve grafting in operative nerve repair and
reconstruction. In:
Gelberman RH, ed. Operative Nerve Repair and Reconstruction. JP Lippincott:
Philadelphia 553–67.
Gilbert A, De Moura W, Salar R, Grossman J (1986) Le prélèvement des greffes
nerveuses. In: Tubiana R, ed. Traité de Chirurgie de la Main. Vol III Masson: Paris,
451–7.
Gu Y, Zheng Y, Li H, Zu Y (1985) Arterialized venous free sural nerve grafting, J Plast
Surg 15:332–8.
Jabaley ME, Wallace WH, Heckler FR (1980) Internal topography of major nerves of the
forearm and hand: a current review, J Hand Surg 5:1–18.
Lebreton E, Bourgeon Y, Lascombes P, Merle M, Foucher G (1983) Vascularisation de
la portion brachiale du nerf ulnaire, Ann Chir Main 2:211–18.
Levinthal R, Brown J, Ran RW (1978) Fascicular nerve allograft. Evaluation. Part 1:
Comparison with autografts by light microscopy, J Neurosurg 48:423–7.
Lundborg G, Hansson HA (1981) Nerve lesions with interruption of continuity. Studies
on the growth pattern of regenerating axons in the gap between the proximal and distal
nerve ends. In: Gorio A, Millesi H, Mingrino S, eds. Posttraumatic Nerve
Regeneration. Raven Press: New York, 229–39.
Lux P, Breidenbach W, Firelli J (1988) Determination of temporal changes in blood flow
in vascularized and non vascularized nerve grafts in the dog, Plast Reconstr Surg
82:133–44.
Lyons WE, George EB, Dawson TM, Steiner JP, Snyder SH (1994) Immunosuppressant
FK 506 promotes neurite out growth in cultures of PC 12 cells and sensory ganglia,
Proc Natl Acad Sci USA 91:3191.
Mackinnon SE, Dellon AC (1988) Surgery of the Peripheral Nerve. Thieme Medical
Publishers: New York, 89–130.
Mackinnon SE, Dellon AL (1990a) Clinical nerve reconstruction with a bioabsorbable
polyglicolic acid tube, Plast Reconstr Surg 85:419–24.
Nerve grafts 187
Mackinnon SE, Dellon AL (1990b) A study of nerve regeneration across synthetic

(Maxon) and biologic (collagen) nerve conduits for nerve gaps up to 5 cm in the
primate, J Reconstr Microsurg 6:117–21.
Mackinnon SE, Hudson AR, Falk RE, Kline D, Hunter DA (1984) Peripheral nerve
allograft: an immunological assessment of pretreatment methods, J Neurosurg
14:167–71.
Mackinnon SE, Midha R, Bain J, Hunter D, Wade J (1992) An assessment of
regeneration across nerve allografts in rats receiving short courses of cyclosporin A
immunosuppression, Neuroscience 46:585–93.
Mackinnon SE, Doolabh VB, Novak CB, Trulock EP (2001) Clinical outcome following
nerve allograft transplantation, Plast Reconstr Surg 107:1419–29.
Madison RD, Da Silva CF, Dikkes P (1988) Entubulation repair with protein additives
increases the maximum nerve gap distance successfully bridged with tubular
prostheses, Brain Res 447:325–34.
McCarty C (1951) Two stage autograft for repair of extensive damage to sciatic nerve, J
Neurosurg 8:318–22.
Merle M (1992) Lésions nerveuses. In: Merle M, Dautel G, eds. La Main Traumatique,
Tome 1: L’urgence. Masson: Paris.
Merle M, Dautel G (1991) Vascularised nerve grafts, J Hand Surg 16B:483–8.
Merle M, Amend PH, Foucher G, Michon J (1984) Plaidoyer pour la réparation primaire
microchirurgicale des nerfs périphériques: Etude comparative de 150 lésions du nerf
médian et cubital avec un recul supérieur à 2 ans, Chirurgie 110:761–71.
Merle M, Dellon AL, Campbell JN, Chang PS (1989) Complications from silicone
polymer intubation of nerves, Microsurgery 10:130–3.
Millesi M, Meissl G, Berger A (1972) The interfascicular nerve-grafting of the median
and ulnar nerves, J Bone Joint Surg 54A:727–50.
Nakao Y, Mackinnon SE, Strasberg SR et al (1995) Immunosuppressive effect of
monoclonal antibodies to ICAM 1 and LFA-1 on peripheral nerve allograft in mice,
Microsurgery 16:612–20.
Oberlin CH, Alnot JY (1985) Utilisation du nerf sciatique poplité externe comme greffe
vascularisée, Rev Chir Orthop 71 (Suppl II):94–8.
Penkert G, Bini W, Samii M (1988) Revascularization of nerve grafts: An experimental
study, J Reconstr Microsurg 4:319–25.
Pho RWH, Lee YS, Rujiwetpongstorn V, Pang M (1985) Histological studies of
vascularized nerve graft and conventional nerve graft, J Hand Surg 10B:45–8.
Pollard JD, Fitzpatrick L (1973) An ultrastructural comparison of peripheral nerve
allografts and autografts, Acta Neuropathol (Berl) 23:.
Restrepo Y, Merle M, Michon J, Foliguet B, Barrat E (1985a) Free vascularized nerve
grafts: an experimental study in the rabbit, Microsurgery 6:78–84.
Restrepo Y, Merle M, Petry D, Michon J (1985b) Empty perineurial tube graft used to
repair a digital nerve: a first case report, Microsurgery 6:73–7.
Rose EH (1985) Restoration of sensibility to anesthetic scarred digits with free
vascularized nerve grafts from the dorsum of the foot, J Hand Surg 10A:593–602.
Rose EH, Kowalski TA, Norris MS (1989) The reversed venous arterialized nerve graft
in digital nerve reconstruction across scarred beds, Plast Reconstr Surg 83:593–602.
Shibata M, Tsai TM, Firelli J, Breidenbach WC (1988) Experimental comparison

between vascularized and non vascularized nerve grafting, J Hand Surg 13A: 358–65.
Strange FGS (1947) An operation for nerve pedicle grafting, Br J Surg 34:423–5.
Strange FGS (1948) The pedicle nerve graft, Br J Surg 35:331–3.
Strasberg SR, Hertl MC, Mackinnon SE et al (1996) Peripheral nerve allograft
preservation improves regeneration and decreases systemic cyclosporin A
requirements, Exp Neurol 139:306–16.
Sunderland S (1945) The intraneural topography of the radial, median and ulnar nerves,
Brain 68:243.
Sunderland S, Marshall RD, Swaney WE (1959) The intraneural topography of the
circumflex, musculocutaneous and obturator nerve , Brain 82:116.
Taylor GI (1978) Nerve grafting with simultaneous microvascular reconstruction, Clin
Orthop Rel Res 133:56–70.
Taylor GI, Ham F (1976) The free vascularized nerve graft, Plast Reconstr Surg 57:413–
26.
Tenny JR, Lewis RC (1984) Digital nerve grafting for traumatic defects, J Bone Joint
Surg (Am) 66:1375–9.
Townsend PLG, Taylor GI (1984) Vascularized nerve grafts using composite arterialized
neuro-venous system, Br J Surg 37:1–17.
Weiss P (1943) Nerve regeneration in the rat following tubular splicing of severed
nerves, Arch Surg 46: 525–47.
Young RC, Wiberg M, Terenghi G (2002) Poly-3-hydroxyburate (PHB): a resorbable
conduit for long-gap repair in peripheral nerves, Br J Plast Surg 55:235–40.
Zalewski AA (1971) The effect of AgB locus. Compatibility and incompatibility on
neuron survival in transplanted sensory ganglia in rats, Exp Neurol 33: 576.
14
Bridging nerve defects: the role of tissue
interpositioning
Göran Lundborg
Bridging a defect in nerve continuity is a very demanding reconstructive surgical

procedure. Several problems are added on top of the difficulties associated with primary
nerve repair. The defect has to be bridged by a conduit capable of guiding regenerating
axons from the proximal to the distal nerve segment. The axons have to pass two suture
lines with the risk of misdirection or loss of axons at both levels. The conduit which
bridges the defect should offer a permissive and stimulating environment for the
traversing nerve fibres (Lundborg 1988). In clinical practice, the most effective conduit
used today is an autologous nerve graft (Millesi 2000). However, a nerve grafting
procedure requires sacrifice of healthy nerves. It is therefore not surprising that extensive
research is on going—aimed at development of alternatives to nerve grafts.
The aim of this chapter is to review the biological principles for a regeneration-
competent nerve conduit and to present various types of tissue interpositioning which are
used experimentally and clinically to bridge nerve defects.
The ideal nerve conduit: a theoretical model
Nerve fibres, traversing a defect, need (1) a matrix/scaffold offering contact guidance and
a framework for the regenerating axons; (2) cells incorporated in the matrix, with
capacity to produce growth factors and to provide a physiological local environment; (3)
growth factors to stimulate the axonal growth, synthesized by cells in the local
environment or supplied locally by other means in experimental systems. When
discussing the construction of a nerve conduit these three factors should be considered—
separately or together (Fig. 1). An interposed conduit of biological or synthetic material
may be tissueengineered to offer these three components in varying proportions and
extent.
A matrix/scaffold can be constructed of synthetic or biological material (Lundborg
1988, 2000, Fields et al 1989, Doolabh et al 1996). A synthetic matrix can consist of
tubes, fibres or other materials of varying topographical shapes and dimensions. It can be
resorbable or nonresorbable. Tubes can be filled with gels containing cells or factors
supporting axonal growth. Among biological matrices basal membranes from nerve and
muscle have been frequently used. Vessels and collagen are examples of other types of
biological material which can be used for tubular structures.
Cells are needed for interaction with the local environment and support of axonal
growth by producing neurotrophic substances. Schwann cells are believed to be the main
source of such factors, but macrophages provided by leaking blood vessels in the nerve
stumps are also important components of the regeneration process (Lundborg 2000).
Cultured Schwann cells have been added to the matrix in many experimental systems.
Cells added to the matrix may be of autologous origin or they may be gene-manipulated
to make them competent to produce specific growth stimulating factors. Addition of stem
cells to the matrix is another promising possibility for the future.
Growth stimulating factors can be added directly to the matrix. In experimental
systems such factors may be provided by, for example
Figure 1
Principles of tissue engineering nerve conduits for bridging
nerve defects. A conduit should consist of a scaffold/
matrix acting in concert with cells and growth factors. The
scaffold/matrix can be biological or non-biological in
nature; resorbable or non-resorbable. It can be of varying
topographical nature such as tubes, fibres or sponges.
Schwann cells are needed for production of growth factors.
Such cells can be precultured in vitro, they may be
incorporated in gels or seeded on longitudinal filament
structures. Cells can be gene-engineered to acquire
competence to produce neutrophic factors. In the future,
stem cells may have a potential to differentiate into
Schwann cells or other types of growth promoting cell.
Neurotrophic factors can be added to the system by slow
release from a bioactive matrix or they can be added from
extrinsic sources.
osmotic pumps or by slow release from a bioactive stroma.

Bridging nerve defects: The role of tissue interpositioning 191
Thus, the ideal conduit for bridging a nerve gap should provide a matrix/scaffold as
well as cells and growth factors. Naturally, the ultimate solution is an autologous nerve
graft since such a graft provides all three components: a matrix constituted by
endoneurial tubes/Schwann cell basal laminae incorporated in connective tissue sheaths
and cells (mainly Schwann cells) producing neurotrophic factors. The autologous nerve
graft therefore is currently the gold standard for bridging nerve defects. However, since
nerve grafting requires sacrifice of healthy nerves, and since large amounts of graft
material occasionally may be needed, there is a strong need for development of
alternatives to nerve grafts. In the search for such alternatives the aim should be to
develop a guide providing the components which are illustrated in Figure 1.
Nerve grafts
Autologous nerve grafts (isografts)

The concept of using autologous nerve grafts for bridging nerve defects was popularized
by Millesi more than 40 years ago (Millesi et al 1972, 1976, Millesi 2000) and is still the
gold standard in nerve reconstruction. To date no other alternative has proved superior to
the use of autologous nerve grafts. Autologous nerve grafts provide a scaffold which
contains Schwann cells basal laminae as well as Schwann cells producing growth factors,
thereby fulfilling the criteria for an ideal nerve conduit as discussed above. The
importance of laminin and fibronectin in the basal lamina scaffolds of nerve grafts has
been emphasized by several investigators (Baron-van Evercooren et al 1982, Wang Nerve
conduits and tissue engineering Proximal nerve segment axons et al 1992, Bailey et al
1993) and these have been found to be ideal to support advancement of regenerating
axons. The Schwann cells in a nerve graft will survive on diffusion, provided the graft is
thin enough, until it is revascularized.
Various types of manipulation can be used to increase the regeneration potential of
autologous nerve grafts, for instance predegeneration (Danielsen et al 1994, Gulati 1996,
Dahlin and Lundborg 1998). The regeneration potential of autologous grafts has been
experimentally improved by non-invasive techniques also such as vibration exposure of
the donor’s hind limb (Bergman et al 1995), and treatment with hyperbaric oxygen
(Zamboni et al 1995, Haapaniemi et al 1998).
Tubes: experimental background
The use of tubes for experimental nerve repair was introduced in the late 1970s as an
interesting model to study nerve regeneration (Lundborg and Hansson 1979, 1980). In the
first studies mesothelial tubes were used for bridging experimental defects in nerve
continuity (Lundborg and Hansson 1979, 1980), but in the early 1980s a silicone tube
model was introduced as an important tool for studying basic biological mechanisms of
nerve regeneration and to analyse effects of manipulating the microenvironment at the
repair site (Lundborg et al 1982a). The concept of tubular repair was based on that nerve
regeneration would be favoured by minimizing surgical trauma, and a short gap between
the nerve ends, encased in a tube, would allow accumulation of the neurotrophic factors
that are normally synthesized in a damaged nerve trunk, with good possibility of the
neurotrophic and neurotropic mechanisms regulating axonal growth to act. When a 10
mm gap was left between proximal and distal ends of a severed rat sciatic nerve and
when the repair side was encased in a tube a very typical and standardized regeneration
process followed: there was, within 4 weeks, a spontaneous formation of a new nerve
structure of more or less normal appearance bridging the defect. The nature and quality of
this nerve structure was directly related to the length of the gap and to the presence of a
distal segment: with a gap length less than 10 mm in a rat sciatic nerve regeneration
always occurred but with gaps exceeding 10–15 mm there was no or inferior regeneration
(Lundborg et al 1982b). The tube model was therefore regarded as an interesting
‘all/or/nothing’ model for axonal growth presenting interesting possibilities to study, in a
simple way, effects of modifying the experimental situation on nerve regeneration, e.g.
supply of various exogenous substances.
The cellular and chemical events occurring in a regeneration chamber follow a
specific pattern. Within hours there is accumulation of fluid inside the chamber
containing neurotrophic factors and various inflammatory cells. At least two types of
neurotrophic activity have been defined in the chamber fluid: Nerve Growth Factor
(NGF) and ciliary neuro trophic factor (CNTF) (Lundborg et al 1982a, Danielsen and
Varon 1995). A major peak in the occurrence of neurotrophic factors has been observed
as soon as 3–6 hours after nerve injury (Danielsen and Varon 1995). The fluid contains
neurotrophic factors as well as various inflammatory cells and cytokines (Longo et al
1983a, b, Danielsen et al 1993). Cells with a pattern characteristic of an ordinary
inflammatory response also accumulate in the tube (Danielsen et al 1993). The
neurotrophic factors in the fluid address sensory, motor and sympathetic neurons.
Within weeks there is a well-organized fibrin matrix being formed inside the tube
bridging the two nerve ends. Laminin as well as fibronectin have been demonstrated early
in the matrix (Longo et al 1984). The fibrin matrix is invaded early by various types of
macrophages (Danielsen et al 1993, Zhao et al 1993, Dahlin et al 1995). The fibrin
orients itself in longitudinal strands. Schwann cells, fibroblasts and microvessels invade
the fibrin matrix from both ends, and the new structure soon becomes revascularized
(Podhajsky and Myers 1994). Axons regenerate into the matrix from the proximal side,
and within months there is an overgrowth of axons into the distal nerve segment. The
matrix is at that time well organized, resembling a normal well vascularized nerve
structure.
Many materials have been used in tube experiments (Fields et al 1989). Tubes may be
permeable or non-permeable to nutrients, cells and vessels, and they may be bio-
resorbable or nonresorbable. Although permeable tubes with holes may allow diffusion of
nutrients and ingrowth of vessels (Jenq and Coggeshall 1985) silicone tubes with holes
do not seem to stimulate axonal ingrowth as compared to tubes with no holes when
applied around a zone of crush injury (Danielsson et al 1996). Several factors like the
interstump gap, the tube lumen area and the microstructure of the inner surface of the
tube lumen are of importance for organization of the axonal growth and for the final
outcome (Lundborg 1988, Aebischer et al 1990, Kim et al 1993, Butí et al 1996, Navarro
et al 1996, ValeroCabré et al 2001).
Manipulation/modification of tube contents for improvement of

regeneration
The regeneration potential of a tube system has been experimentally improved by various
modifications, for example, by varying the size of the chamber or filling it with dialyzing
plasma (Williams 1987). Introduction of laminin, collagen, fibrin and fibronectin into
tubes has been shown to have a positive influence on regeneration (Madison et al 1985,
1987, 1988, Müller et al 1987, Valentini et al 1987, Rosen et al 1990, Kljavin and
Madison 1991, Bailey et al 1993, Tong et al 1994, Zeng et al 1995, Labrador et al 1998,
Rodriguez et al 2000). Stimulation of regeneration by the introduction of testosterone,
gangliosides (Müller et al 1987), Matrigel (Guénard et al 1992) or hyalyron (Seckel et al
1995) as well as cultured adult Schwann cells into the tube has also been attempted
(Guénard et al 1992, Kim et al, 1994, Ansselin et al 1997, Levi et al 1997). In addition,
neurotrophic factors such as NGF (Rich et al 1989) and fibroblast growth factor (FGF)
(Danielsen et al 1988, Rich et al 1989) have been used to stimulate the regeneration
process.
Longitudinal synthetic filaments introduced inside silicone tubes have been used to
increase the regeneration competence of such conduits. Defects of 15 mm in rat sciatic
nerve, which can not be bridged by a tube alone, were successfully bridged by the use of
such ‘bioartificial nerve grafts’ (Lundborg and Kanje 1996, Lundborg et al 1997b). In
this model filaments made of polyamide or polyglactin helped to stabilize the fibrin
matrix which is formed inside the tube, and regenerating axons together with Schwann
cells and microvessels advanced inbetween the filaments (Fig. 2) (Lundborg and Kanje
1996, Lundborg et al 1997b, Terada et al 1997a,b,c, Dahlin and Lundborg 1999, Arai et
al 2000).
Silicone tubes have been successfully used in the situation clinical for repair of median
and ulnar nerves in the human forearm (Lundborg et al 1991, 1994, 1997a). In a
randomized prospective clinical study the outcome was compared between routine
microsurgical repair and a tubular repair where the nerve ends were intentionally left 3–4
mm apart inside the tube. At follow-up, 12 months later, there was no difference in the
outcome regarding sensory or motor function (Lundborg et al 1997a). Also, at followup 5
years postoperatively the functional outcome was the same in the two groups although
the tubular group showed less cold intolerance (Lundborg et al, in press).
Biodegradable polymer tubes
Tubes consisting of various biodegradable materials, such as polyglycolic acid (PGA)

have been successfully used both experimentally and clinically for bridging nerve defects
(Reid et al 1978, Molander et al 1982, 1983, Dellon and Mackinnon 1988, Mackinnon
and Dellon 1990a). PGA tubes were shown to support successfully regeneration across 3
cm defects in the ulnar nerves of monkeys (Dellon and Mackinnon 1988). In other
experiments in monkeys glycolide trimethylene carbonate (Maxon) conduits were used to
bridge 2 cm nerve gaps with good results (Mackinnon and Dellon 1990b). These conduits
supported some regeneration even across defects as long as 5 cm.
PGA tubes were successfully used in patients to bridge digital nerve gaps of 0.5–3.0
cm (mean 1.7 cm) (Mackinnon and Dellon 1990a). A randomized prospective multicentre
study on the use of PGA conduits for human digital nerve construction was performed by
Weber et al (2000). PGA conduits were found useful and compared well to nerve grafts
and end-to-end repair in conduit repair for nerve gaps of 4 mm or less. PGA tubes have
also been successfully used to reconstruct a 25 mm defect in the right inferior alveolar
nerve (Crawley and Dellon 1992). At
Figure 2
A type of bioartificial nerve graft based on synthetic
material. (a) Longitudinal synthetic filaments are
introduced into a silicone tube. The filaments can be non-
resorbable, e.g. polyamide, or resorbable, e.g. polyglactin.
The filaments help to stabilize the fibrin matrix as
illustrated in the insert; (b) There is vigorous growth of
myelinated axons in the fibrin matrix inbetween the
filaments. Asterix indicates polyamide filament. (c) The
same area in higher magnification. Scale: bar = 25 µm.
Reproduced with permission from Lundborg and Kanje
1997b.
2 years follow-up the perception of pressure and vibration at the nerve reconstruction was
similar to the contralateral side of the lip.
Navarro and co-workers have performed extensive studies on the use of nerve guides
in mice with special reference to tube material and tube contents (Navarro et al 1994,
1996, 2001, Butí et al 1996, Gomez et al 1996, Rodriguez et al 1999, 2000, Valero-Cabré
et al 2001). They used a mouse sciatic nerve model in which various types of tubular
conduit were used to bridge a nerve gap of 6 mm. They found resorbable guides made of
collagen or polylactate caprolactone (PLC) superior to non-resorbable guides such as
silicone, Teflon or Polysylfone. Cultured Schwann cells suspended in Matrigel,
introduced in the tubes, were important factors contributing to successful nerve
regeneration (Rodriguez et al 2000).
Collagen tubes
Collagen tubes have been used for bridging nerve defects in mice (Gomez et al 1996,
Navarro et al 1996), rabbits (Kim et al 1993) and primates (Mackinnon and Dellon
1990b, Li et al 1992, Archibald et al 1995, Madison and Archibald 1996). Krarup et al
performed extensive studies on factors that influence peripheral nerve regeneration
through collagen tubes in monkeys (Krarup et al 2002). Nerve gap distances of various
lengths were repaired with collagenbased nerve guides, and extensive neurophysiological
investigations were performed postoperatively over a period of 3–4 years. It was found
that nerve gap distance and the type of repair strongly influenced the time to the earliest
muscle reinnervation. Nerve gaps up to 5 cm were successfully bridged by the collagen-
based nerve guide tube (Krarup et al 2002).
Longitudinally oriented suture material
Longitudinal sutures alone, without an artificial tube, can support regeneration across
defects in the rat sciatic nerve. Scherman et al (2000a,b, 2001a) bridged 7–15 mm gaps in
the rat sciatic nerve by parallel strands of 8–0 sutures of either polyglactin or polyamide
(Fig. 3). It was found that the sutures served as an effective scaffold for generation of a
new nerve structure across the gap. A matrix containing capillaries, fibroblast-like cells
and mononuclear cells were rapidly formed in the tissue inbetween the sutures. Axons,
advancing between the longitudinal suture strands were organized in minifascicles and,
with time, became surrounded by a perineurium-like structure. No difference in axonal
counts or degree of myelination was observed between polyamide and polyglactin. For
bridging of 7 mm gaps the suture model showed no difference in regeneration capacity as
compared to conventional nerve grafts. In the 15 mm gap group, axonal regeneration
across a 15 mm gap was significantly enhanced when a short interposed nerve segment
was attached to the sutures halfway (a ‘stepping-stone’ procedure). The interposed nerve
segment acted as a Schwann cell resource in this model. Pretreatment of the sutures with
triiodothyronine (T3) enhanced the myelination process in the regenerating nerve
structure (Scherman et al 2001b). It was concluded that conventional longitudinally
oriented sutures bridging a defect may be sufficient to support regeneration across short
gaps in peripheral nerves, a method which may be of considerable potential clinical value
(Scherman et al 2000a,b, 2001a).
Basal laminin as scaffolds
Basal membranes from muscle or nerve can provide a matrix in a nerve guide. It was
demonstrated about 20 years ago that basal laminae tubes from muscle tissue could serve
as guiding structures for growing axons (Ide et al 1983). Muscle basal laminae contain
laminin and fibronectin and may thereby support axonal ingrowth (for a review see Hall
1997). Based on this concept coaxial frozen and thawed muscle grafts have been used for
bridging gaps in nerve continuity (Keynes et al 1984, Fawcett and Keynes 1986, Glasby
et al 1986a,b, 1992, Gschmeissner et al 1988, Feneley et al 1991, Glasby 1991).
Regeneration is limited by the length of such grafts: in rabbit common peroneal nerve a 5
cm gap could be successfully bridged while in more extensive defects regeneration was
impaired compared to nerve grafts (Hems and Glasby 1993). Introduction of a small
nerve segment in the middle of a muscle graft (‘sandwich graft’) can increase the
regeneration capacity (Calder and Green 1995, Whitworth et al 1995c). Besides freezing
and thawing, muscle grafts also can be made acellular by chemical extraction by Triton
x-100 (Packard, USA) (Arai et al 2001, Xiao-Lin et al 2001). Such grafts show good
regeneration competence when used for bridging defects in rat sciatic nerve. In clinical
trials coaxial autografts of freeze-thawed skeletal muscle have been used to repair injured
digital nerves (Norris et al 1988). At follow-up 3–11 months after the operation all but
one patient showed an excellent level of recovery. Precultured Schwann cells, added to
frozen and thawed muscle grafts have been shown to improve the regeneration
competence of the graft (Fansa et al 1999, Nishiura et al, 2001a,b).
Figure 3
Longitudinal sutures alone, bridging a gap, can serve as a
framework for generation of a new nerve structure. (a)
Principles for longitudinal suture arrangement: I, 7 mm
gap, no conduit; II, continuous longitudinal sutures
bridging a 7 mm gap as compared to a standard nerve
autograft on the contralateral side; III, 15 mm gaps bridged
by sutures alone or a 2 mm interposed nerve segment
threaded onto the sutures on the contralateral side. (b)
Axons are advancing in the tissue space inbetween the
longitudinal suture material. There are numerous large
minifascicles containing numerous axons after 12 weeks.
Reproduced with permission from Scherman et al 2001a.
Besides muscle basal laminae, basal laminae from nerves may also serve as nerve
guides in experimental systems. Nerve allografts, made acellular through chemical
extraction, have been used to bridge 10 mm defects in rat sciatic nerves. Such grafts were
found to support outgrowth of axons and migration of Schwann cells which reoccupy the
empty basal lamina tubes without excessive signs of inflammation (Sondell et al 1998).
Vascular endothelial growth factor (VEGF), when added to such grafts, had neurotrophic
activity and stimulated Schwann cell proliferation as well as axonal outgrowth (Sondell et
al 1999).
Veins
Veins have been used successfully for bridging nerve gaps (Chiu et al 1982, Foidart-
Dessalle et al 1997). An original observation (Chiu et al 1982, 1988) that a 10 mm gap of
rat sciatic nerve could successfully be bridged by autologous vein grafts evolved from an
experimental idea to a clinical reality showing successful reconstruction of peripheral
nerves with a nerve gap of less then 3 cm in patients (Chiu and Strauch 1990, Chiu 1999).
Vein–muscle conduits
Combined vein–muscle nerve conduits have been used by Battiston et al to bridge 1–2
cm gaps in rat sciatic nerve. The principle was that a piece of fresh muscle inside the vein
would expand the vessel, and that the muscle basal lamina would help to support axonal
overgrowth (Battiston et al 2000a,b, Geuna et al 2000a,b, Tos et al 2000, Fornaro et al
2001). In the Battiston experimental model these conduits serve well as guides for axonal
overgrowth, and the principle has been applied in more than 20 clinical cases followed
for more than 1 year with encouraging results (Battiston et al 2000a).
Autologous tendons as graft
Collagen fibres have been used as a matrix for regenerating axons in rats, bridging gaps
up to 30 mm (Yoshii et al 2001, 2002). Collagen fibres from rat tail tendon were used by
Brandt et al to bridge defects of varying lengths in the sciatic nerve of rats (Brandt et al
1999a,b, 2002a). In these models the tendon was either used in its original shape or was
teased and subsequently rolled to form a loose collagen roll which was used to bridge
defects of 10–15 mm (Fig. 4). Such tendon structures served as effective conduits for
axonal growth and were found to be comparable to freeze-thawed muscle grafts (Brandt
et al 2002a). In vitro colonization of Schwann cells in tendon autografts prior to grafting
was found to enhance significantly the regeneration process (Brandt et al 2002b). It was
also shown that acutely dissociated Schwann cells, from the ends of a previously severed
nerve, when seeded in a tendon autograft for bridging nerve defects in rats, increased the
regeneration competence of the conduit (Brandt 2002).
Fibronectin and laminin grafts
Conduits made out of laminin (Kauppila et al 1993) have been used to bridge defects in
nerve continuity in rats, and fibronectin mats have been successfully used as conduits for
bridging 10 mm gaps in rat sciatic nerves (Whitworth et al 1995a, 1996). It has been
demonstrated that the addition of neurotrophic factors such as NGF can enhance nerve
regeneration (Whitworth et al 1995b, 1996) and can also decrease post-traumatic nerve
cell body death in dorsal root ganglia in rats (Rich et al 1987) and monkeys (Ahmed et al
1999, Wiberg et al 1999). Also neurotrophin-3 (NT-3) delivered locally via fibronectin
mats has been shown to increase peripheral nerve regeneration in rats (Sterne et al 1997).
Alginate conduits
Freeze-dried alginate gels covered with a polyglycolic acid mesh have been used
successfully to bridge 50 mm gaps in cat sciatic nerves with good functional results
(Suzuki et al 1999). Alginates have been used experimentally for facial nerve repair also.
In cats alginate sponges were used to bridge 5 mm gaps in the dorsal ramus of the facial
nerve with good behavioural, electrophysiological and histological results after 4 months
(Wu et al 2002).
Polyhydroxybutyrate
Poly-3-hydroxybutyrate (PHB) is a natural biological polymer used as a bacterial storage

product, and manufactured as bioresorbable sheaths. PHB has been successfully used to
bridge long nerve gaps (up to 4 cm) in a rabbit common peroneal nerve injury model
(Young et al 2002). PHB, wrapped around a nerve repair site, has been successfully used
as an alternative to nerve suture in rats (Hazari et al 1999a) and cats (Hazari 1999b,
Ljungberg et al 1999). Addition of allogeneic Schwann cells to the PHB conduits
increased their regeneration competence (Mosahebi et al 2002).
Figure 4
Tendon used as nerve graft. (a) A rat tail tendon can be
teased to a membrane exposing numerous parallel collagen
fibres. Such a membrane can be rolled to form a tube and
can also be co-cultured with Schwann cells in vitro.
Reproduced with permission from Brandt 2002c. (b) When
a tendon is used as a conduit for bridging a nerve gap
myelinated axons can be seen advancing inbetween the
collagen components after 4 weeks. Scale: bar = 100 µm.
(c) The same area at higher magnification. Scale: bar = 50
µm. (Reproduced with courtesy of Dr J Brandt.)
Conclusions
The ideal nerve conduit consists of a matrix favouring axonal advancement and acting in
concert with Schwann cells producing neurotrophic factors. Although autologous nerve
grafts offering these components constitute the gold standard, evolving tissue engineering
techniques have already provided alternative conduits with a regeneration competence
approaching the competence of nerve grafts in experimental animal systems. Synthetic
tubular structures have already been used clinically for bridging short defects in digital
nerves as well as ulnar and median nerves in the human forearm. Various types of
biological systems as well as various synthetic structures, tissue-engineered to contain
appropriate cells and growth factors, may in the future be an important alternative to
autologous nerve grafts.
Acknowledgements
Research on nerve injury and repair at our department is supported by the Medical
Research Council; Faculty of Medicine, Lund University; and Malmö University
Hospital.
References
Aebischer P, Guénard V, Valentini RF (1990) The morphology of regenerating peripheral

nerves is modulated by the surface microgeometery of polymeric guidance channels,
Brain Res 531:211–18.
Ahmed Z, Brown RA, Ljungberg C et al (1999) Nerve growth factor enhances peripheral
nerve regeneration in non-human primates, Scand J Plast Reconstr Hand Surg
33:393–401.
Ansselin AD, Fink T, Davey DF (1997) Peripheral nerve regeneration through nerve
guides seeded with adult Schwann cells, Neuropathol Appl Neurobiol 23:387–98.
Arai T, Lundborg G, Dahlin L (2000) Bioartificial nerve graft for bridging extended
nerve defects based on resorbable guiding filaments, Scand J Plast Reconstr Hand
Surg 34:101–8.
Arai T, Kanje M, Lundborg G et al (2001) Axonal outgrowth in muscle grafts made
acellular by chemical extraction, Restor Neurol Neurosci 17:165–74.
Archibald SJ, Shefner J, Krarup C et al (1995) Monkey median nerve repaired by nerve
graft or collagen nerve guide tube , J Neurosci 15:4109–23.
Bailey SB, Eichler ME, Villadiego A et al (1993) The influence of fibronectin and
laminin during Schwann cell migration and peripheral nerve regeneration through
silicone chambers, J Neurocytol 22:176–84.
Baron-Van Evercooren A, Kleinman HK, Ohno S et al (1982) Nerve growth factor,
laminin, and fibronectin promote neurite growth in human fetal sensory ganglia
cultures, J Neurosci Res 8:179–93.
Battiston B, Tos P, Cushway T et al (2000a) Nerve repair by means of vein filled with
muscle grafts. I. Clinical results, Microsurgery 20:32–6.
Battiston B, Tos P, Geuna S et al (2000b) Nerve repair by means of vein filled with
muscle grafts. II. Morphological analysis of regeneration, Microsurgery 20:37–41.
Bergman S, Widerberg A, Danielsen N et al (1995) Nerve regeneration in nerve grafts
conditioned by vibration exposure, Restor Neurol Neurosci 7:165–9.
Brandt J (2002) Tendon autografts for bridging nerve defects, Thesis, Lund University.
Brandt J, Dahlin LB, Lundborg G (1999a) Autologous tendons as grafts for bridging
peripheral nerve defects, J Hand Surg 24B:284–90.
Brandt J, Dahlin LB, Kanje M et al (1999b) Spatiotemporal progress of nerve
regeneration in a tendon autograft used for bridging a peripheral nerve defect, Exp
Neurol 160:386–93.
Brandt J, Dahlin LB, Kanje M et al (2002a) Functional recovery in a tendon autograft
used to bridge a peripheral nerve defect, Scand J Plast Reconstr Surg Hand Surg
36:2–8.
Brandt J, Lundborg G, Dahlin LB et al (2002b) A Schwann cell seeded tendon autograft

used for peripheral nerve repair. Poster, VIIIth FESSH Congress, Amsterdam May
22–25.
Butí M, Verdú E, Labrador RO et al (1996) Influence of physical parameters of nerve
chambers on peripheral nerve regeneration and reinnervation, Exp Neurol 137:26–33.
Calder JS, Green CJ (1995) Nerve-muscle sandwich grafts: the importance of Schwann
cells in peripheral nerve regeneration through muscle basal lamina conduits, J Hand
Surg 20B:423–8.
Chiu DT (1999) Autogenous venous nerve conduits. A review, Hand Clin 15:667–71.
Chiu DT, Strauch B (1990) A prospective clinical evaluation of autogenous vein grafts
used as a nerve conduit for distal sensory nerve defects of 3 cm or less, Plast Reconstr
Surg 86:928–34.
Chiu DT, Janecka I, Krizek TJ et al (1982) Autogenous vein graft as a conduit for nerve
regeneration, Surgery 91:226–33.
Chiu DT, Lovelace RE, Yu LT et al (1988) Comparative electrophysiologic evaluation of
nerve grafts and autogenous vein grafts as nerve conduits: an experimental study, J
Reconstr Microsurg 4:303–9, 311–12.
Crawley WA, Dellon AL (1992) Inferior alveolar nerve reconstruction with a
polyglycolic acid bioabsorbable nerve conduit, Plast Reconstr Surg 90:300–2.
Dahlin LB, Lundborg G (1998) Experimental nerve grafting—towards future solutions of
a clinical problem, J Hand Surg 3:165–73.
Dahlin L, Lundborg G (1999) Bridging defects in nerve continuity: influence of
variations in synthetic fiber composition, J Material Sci: Materials in Medicine
10:549–53.
Dahlin LB, Zhao Q, Bjursten LM (1995) Nerve regeneration in silicone tubes:
distribution of macrophages and interleukin-1β in the formed fibrin matrix, Restor
Neurol Neurosci 8:199–203.
Danielsen N, Varon S (1995) Characterization of neurotrophic activity in the silicone
chamber model for nerve regeneration, J Reconstr Microsurg 11:231–5.
Danielsen N, Pettman B, Vahlsing HL et al (1988) Fibroblast growth factor effects on
peripheral nerve regeneration in a silicone chamber model, J Neurosci Res 20:320–30.
Danielsen N, Dahlin LB, Thomsen P (1993) Inflammatory cells and mediators in the
silicone chamber model for nerve regeneration, Biomaterials 14:1180–5.
Danielsen N, Kerns JM, Holmquist B et al (1994) Predegenerated nerve grafts enhance
regeneration by shortening the initial delay period, Brain Res 666:250–4.
Danielsson P, Dahlin LB, Povlsen B (1996) Increased axonal outgrowth following a
crush injury to the rat sciatic nerve by encapsulating the zone of regeneration in a
silicone tube, Exp Neurol 139:238–43.
Dellon AL, MacKinnon SE (1988) An alternative to the classical nerve graft for the
management of the short nerve gap, Plast Reconstr Surg 82:849–56.
Doolabh VB, Hertl MC, Mackinnon SE (1996) The role of conduits in nerve repair: a
review, Rev Neurosci 7:47–84.
Fansa H, Keilhoff G, Forster G et al (1999) Acellular muscle with Schwann-cell
implantation: an alternative biologic nerve conduit, J Reconstr Microsurg 15:531–7.
Fawcett JW, Keynes RJ (1986) Muscle basal lamina: a new graft material for peripheral
nerve repair, J Neurosurg 65:354–63.
Feneley MR, Fawcett JW, Keynes RJ (1991) The role of Schwann cells in the
regeneration of peripheral nerve axons through muscle basal lamina grafts, Exp Neurol
114:275–85.
Fields RD, Le Beau JM, Longo FM et al (1989) Nerve regeneration through artificial
tubular implants, Progr Neurobiol 33:87.
Foidart-Dessalle M, Dubuisson A, Lejeune A et al (1997) Sciatic nerve regeneration
through venous or nervous grafts in the rat, Exp Neurol 148:236–46.
Fornaro M, Tos P, Geuna S et al (2001) Confocal imaging of Schwann-cell migration
along muscle-vein combined grafts used to bridge nerve defects in the rat,
Geuna S, Tos P, Battiston B et al (2000a) Morphological analysis of peripheral nerve
regenerated by means of vein grafts filled with fresh skeletal muscle, Anat Embryol
201:475–82.
Geuna S, Tos P, Battiston B et al (2000b) A stereological study of long-term regeneration
of rat severed sciatic nerve repaired by means of muscle-vein-combined grafts, Int J
Anat Embryol 105:65–73.
Glasby MA (1991) Interposed muscle grafts in nerve repair in the hand: an experimental
basis for future clinical use, World J Surg 15:501–10.
Glasby MA, Gschmeissner SG, Hitchcock RJI et al (1986a) The dependence of nerve
regeneration through muscle grafts in the rat on the availability and orientation of
basement membrane, J Neurocytol 15:497–510.
Glasby MA, Gschmeissner SG, Huang CI et al (1986b) Degenerated muscle graft used
for peripheral nerve repair in primates, J Hand Surg 11B:347–51.
Glasby MA, Carrick MJ, Hems TEJ (1992) Freezethawed skeletal muscle autografts used
for brachial plexus repair in the non-human primate, J Hand Surg 17B:526–35.
Gomez N, Cuadras J, Buti M et al (1996) Histologic assessment of sciatic nerve
regeneration following resection and graft or tube repair in the mouse, Restor Neurol
Neurosci 10:187–96.
Gschmeissner SG, Gattuso JM, Glasby MA et al (1988) Functional reinnervation of
muscles after nerve repair with muscle grafts. Demonstration using a new combined
stain, Neuro-Orthopedics 5:1–9.
Guénard V, Kleitman N, Morrissey TK et al (1992) Syngeneic Schwann cells derived
from adult nerves seeded in semipermeable guidance channels enhance peripheral
nerve regeneration, J Neurosci 12:3310–20.
Gulati AK (1996) Peripheral nerve regeneration through short-and long-term degenerated
nerve transplants, Brain Res 742:265–70.
Haapaniemi T, Nylander G, Kanje M et al (1998) Hyperbaric oxygen treatment enhances
regeneration of the rat sciatic nerve, Exp Neurol 149:433–8.
Hall S (1997) Axonal regeneration through acellular muscle grafts, J Anat 190:57–71.
Hazari A, Johansson Ruden G, Junemo-Bostrom K et al (1999a) A new resorbable wrap-
around implant as an alternative nerve repair technique, J Hand Surg (Br) 24:291–5.
Hazari A, Wiberg M, Johansson Ruden G et al (1999b) A resorbable nerve conduit as an
alternative to nerve autograft in nerve gap repair, Br J Hand Surg 52:633–57.
Hems TEJ, Glasby MA (1993) The limit of graft length in the experimental use of muscle
grafts for nerve repair, J Hand Surg 18B:165–70.
Ide C, Tohyama K, Yokota R et al (1983) Schwann cell basal lamina and nerve
regeneration, Brain Res 288:61–75.
Jenq CB, Coggeshall RE (1985) Nerve regeneration through holey silicone tubes, Brain
Res 361:233–41.
Kauppila T, Jyväsjärvi E, Huopaniemi T et al (1993) A laminin graft replaces
neurorrhaphy in the restorative surgery of the rat sciatic nerve, Exp Neurol 123:181–
91.
Keynes RJ, Hopkins WG, Huang LH (1984) Regeneration of mouse peripheral nerves in
degenerating skeletal muscle: guidance by residual muscle fibre basement membrane,
Brain Res 295:275–81.
Kim DH, Connolly SE, Zhao S et al (1993) Comparison of macropore, semipermeable,
and nonpermeable collagen conduits in nerve repair, J Reconstr Microsurg 9:415–20.
Kim DH, Connolly SE, Kline DG et al (1994) Labeled Schwann cell transplants versus
sural nerve grafts in nerve repair, J Neurosurg 80:254–60.
Kljavin IJ, Madison RD (1991) Peripheral nerve regeneration within tubular prostheses:
effects of laminin and collagen matrices on cellular ingrowth, Cell Materials 1:17–28.
Krarup C, Archibald S, Madison R (2002) Factors that influence peripheral nerve
regeneration: an electrophysiological study of the monkey median nerve, Ann Neurol
51:69–81.
Labrador RO, Butí M, Navarro X (1998) Influence of collagen and laminin matrices on
nerve regeneration after resection and tube repair, Exp Neurol 149:243–52.
Levi AD, Sonntag VK, Dickman C et al (1997) The role of cultured Schwann cell grafts
in the repair of gaps within the peripheral nervous system of primates, Exp Neurol
143:25–36.
Li S-T, Archibald SJ, Krarup C et al (1992) Peripheral nerve repair with collagen
conduits, Clin Materials 9:195–200.
Ljungberg C, Johansson-Ruden G, Bostrom KJ et al (1999) Neuronal survival using a
resorbable synthetic conduits as an alternative to primary nerve repair, Microsurgery
19:259–64.
Longo FM, Manthorpe M, Skaper SD et al (1983a) Neuronotropic activities accumulate
in vivo within silicone nerve regeneration chambers, Brain Res 261:109–17.
Longo FM, Skaper SD, Manthorpe M et al (1983b) Temporal changes of neuronotropic
activities accumulating in vivo within nerve regeneration chambers, Exp Neurol
81:756–69.
Longo FM, Hayman EG, Davis GE et al (1984) Neuritepromoting factors and
extracellular matrix components accumulating in vivo within nerve regeneration
chambers, Brain Res 309:105–17.
Lundborg G (1988) Nerve Injury and Repair. Churchill Livingstone: Edinburgh.
Lundborg G (2000) A 25-year perspective of peripheral nerve surgery: evolving
neuroscientific concepts and clinical significance, J Hand Surg 25A:391–414.
Lundborg G, Hansson HA (1979) Regeneration of peripheral nerve through a preformed
tissue space—preliminary observations on the reorganization of regenerating nerve
fibres and perineurium, Brain Res 178:673–6.
Lundborg G, Hansson HA (1980) Nerve regeneration through preformed pseudosynovial
tubes. A preliminary report on a new experimental model for study of the regeneration
and reorganization of peripheral nerves, J Hand Surg 5:35–8.
Lundborg G, Kanje M (1996) Bioartificial nerve grafts—a prototype, Scand J Plast

Reconstr Hand Surg 30:105–10.
Lundborg G, Longo F, Varon S (1982a) Nerve regeneration model and neuronotrophic
factors in vivo, Brain Res 232:157–61.
Lundborg G, Dahlin LB, Danielsen N et al (1982b) Nerve regeneration in silicone
chambers: influence of gap length and of distal stump components , Exp Neurol
76:361–75.
Lundborg G, Longo F, Varon S (1982a) Nerve regeneration model and neuronotrophic
factors in vivo, Brain Res 232:157–61.
Lundborg G, Dahlin LB, Danielsen N (1991) Ulnar nerve repair by the silicone chamber
technique, Scand J Plast Reconstr Hand Surg 25:79–82.
Lundborg G, Rosén B, Abrahamsson S-O et al (1994) Tubular repair of the median nerve
in the human forearm. Preliminary findings, J Hand Surg 19B: 273–6.
Lundborg G, Rosén B, Dahlin L et al (1997a) Tubular vs conventional repair of median
and ulnar nerves in the human forearm—early results from a prospective, randomized
clinical study, J Hand Surg 22A:99–106.
Lundborg G, Dahlin LB, Kanje M et al (1997b) A new type of ‘bioartificial’ nerve graft
for bridging extended defects in nerve, J Hand Surg 22B:299–303.
Lundborg G, Rosén B, Dahlin L et al (2003) Tubular repair of the median and ulnar nerve
in the human forearm: a five year follow-up.
Mackinnon SE, Dellon AL (1990a) Clinical nerve reconstruction with a bioresorbable
polyglycolic acid tube, Plast Reconstr Surg 85:419–24.
Mackinnon SE, Dellon AL (1990b) A study of nerve regeneration across synthetic
(Maxon) and biologic (collagen) nerve conduits for nerve gaps up to 5 cm in the
primate, J Reconstr Microsurg 6:117–21.
Madison RD, Archibald SJ (1996) Potential value of synthetic tubes for nerve repair. In:
Wilkins RH,
Rengachary SS, eds. Neurosurgery, 2nd edn. McGrawHill: New York.
Madison R, da Silva CF, Dikkes P et al (1985) Increased rate of peripheral nerve
regeneration using bioresorbable nerve guides and a laminin-containing gel, Exp
Neurol 88:767–72.
Madison RD, da Silva C, Dikkes P et al (1987) Peripheral nerve regeneration with
entubulation repair: comparison of biodegradeable nerve guides versus polyethylene
tubes and the effects of a laminin-containing gel, Exp Neurol 95:378–90.
Madison RD, Da Silva CF, Dikkes P (1988) Entubulation repair with protein additives
increases the maximum nerve gap distance successfully bridged with tubular
prostheses, Brain Res 447:325–34.
Millesi H (2000) Techniques for nerve grafting, Hand Clin 16:73–91.
Millesi H, Meissl G, Berger A (1972) The interfascicular nerve grafting of the median
and ulnar nerves, J Bone Joint Surg 54A:727–50.
Millesi H, Meissl G, Berger A (1976) Further experience with interfascicular grafting of
the median, ulnar, and radial nerves, J Bone Joint Surg 58A:209–17.
Molander H, Olsson Y, Engkvist O et al (1982) Regeneration of peripheral nerve through
a polyglactin tube, Muscle Nerve 5:54–7.
Molander H, Engkvist O, Hägglund J et al (1983) Nerve repair using a polyglactin tube
and nerve graft: an experimental study in the rabbit, Biomaterials 4:276–80.
Mosahebi A, Fuller P, Wiberg M et al (2002) Effect of allogeneic Schwann cell

transplantation on peripheral nerve regeneration, Exp Neurol 173:213–23.
Müller H, Williams LR, Varon S (1987) Nerve regeneration chamber: evaluation of
exogenous agents applied by multiple injections, Brain Res 413:320–6.
Navarro X, Verdú E, Butí M (1994) Comparison of regenerative and reinnervating
capabilities of different functional types of nerve fibers, Exp Neurol 129:217–24.
Navarro X, Rodríguez FJ, Labrador RO et al (1996) Peripheral nerve regeneration
through bioresorbable and durable nerve guides, J Periph Nerv Syst 1:53–64.
Navarro X, Udina E, Ceballos D et al (2001) Effects of FK506 on nerve regeneration and
reinnervation after graft or tube repair of long gaps, Muscle Nerve 24:905–15.
Nishiura Y, Yasmuaza T, Kanje M et al (2001a) Transplantation of cultured Schwann
cells to teased tendon grafts and freeze thawed muscle grafts improves nerve
regeneration. Poster presentation, 8th IFSSH Congress, Istanbul, Turkey June 10–14.
Nishiura Y, Brandt J, Nilsson A et al (2001b) Addition of cultured Schwann cells to
tendon autografts and freeze-thawed muscle grafts improves peripheral nerve
regeneration. Abstract presented at the 31st Annual
Meeting of the Society for Neuroscience, San Diego, CA, USA November 10–15.
Norris RW, Glasby MA, Gattuso JM et al (1988) Peripheral nerve repair in humans using
muscle autografts: a new technique, J Bone Joint Surg 70B:530–3.
Podhajsky RJ, Myers RR (1994) The vascular response to nerve transection:
Neovascularization in the silicone nerve regeneration chamber, Brain Res 662:88–94.
Reid RI, Cutright DE, Garrison JS (1978) Biodegradable cuff. An adjunct to peripheral
nerve repair: a study in dogs, Hand 10:259–66.
Rich KM, Luszczynski JR, Osborne P et al (1987) Nerve growth factor protects adult
sensory neurons from cell death and atrophy caused by nerve injury, J Neurocytol
16:261–8.
Rich KM, Alexander TD, Pryor JC et al (1989) Nerve growth factor enhances
regeneration through silicone chambers, Exp Neurol 105:162–70.
Rodriguez FJ, Gomez N, Perego G et al (1999) Highly permeable polyactide-
caprolactone nerve guides enhance peripheral nerve regeneration through long gaps,
Biomaterials 29:1489–500.
Rodriguez FJ, Verdu E, Ceballos D et al (2000) Nerve guides seeded with autologous
Schwann cells improve nerve regeneration, Exp Neurol 161:571–84.
Rosen JM, Padilla JA, Nguyen KD et al (1990) Artificial nerve graft using collagen as an
extracellular matrix for nerve repair compared with sutured autograft in a rat model,
Ann Plast Surg 25:375–87.
Scherman P, Lundborg G, Kanje M et al (2000a) Sutures alone are sufficient to support
regeneration across a gap in the continuity of the sciatic nerve in rats, Scand J Plast
Reconstr Hand Surg 34:1–8.
Scherman P, Kanje M, Lundborg G et al (2000b) Continuous longitudinal sutures—a new
and simple approach to repair nerve defects, J Hand Surg 25B (Suppl 1):44.
Scherman P, Lundborg G, Kanje M et al (2001a) Neural regeneration along longitudinal
polyglactin sutures across short and extended defects in the rat sciatic nerve, J
Neurosurg 95:316–23.
Scherman P, Lundborg G, Kanje M et al (2001b) Triiodothyronine treated polyglactin

sutures enhance myelination in regeneration in a cross sciatic nerve defect in the rat.
Poster presentation, 8th IFSSH Congress, Istanbul, Turkey June 10–14.
Seckel BR, Jones D, Hekimian KJ et al (1995) Hyaluronic acid through a new injectable
nerve guide delivery system enhances peripheral nerve regeneration in the rat, J
Neurosci Res 40:318–24.
Sondell M, Lundborg G, Kanje M (1998) Regeneration of the rat sciatic nerve into
allografts made acellular through chemical extraction, Brain Res 795:44–54.
Sondell M, Lundborg G, Kanje M (1999) Vascular endothelial growth factor (VEGF)
stimulates Schwann cell invasion and neovascularization in acellular nerve grafts, J
Sterne GD, Brown RA, Green CJ et al (1997) Neurotrophin-3 delivered locally via
fibronectin mats enhances peripheral nerve regeneration, Eur J Neurosci 9:1388–96.
Suzuki Y, Tanihara M, Ohnishi K et al (1999) Cat peripheral nerve regeneration across
50 mm gap repaired with a novel nerve guide composed of freeze-dried alginate gel,
Neurosci Lett 259:75–8.
Terada N, Lundborg G, Bjursten LM et al (1997a) Bioartificial nerve grafts based on
absorbable guiding filament structures—early observations, Scand J Plast Reconstr
Surg Hand Surg 31:1–6.
Terada N, Bjursten LM, Papaloizos M et al (1997b) Resorbable filament structures as a
scaffold for matrix formation and axonal growth in bioartificial nerve grafts—long
term observations, Rest Neurol Neurosci 11:65–9.
Terada N, Lundborg G, Bjursten LM et al (1997c) The role of macrophages in
bioartificial nerve grafts based on resorbable guiding filament structures, J Med Mat
8:391–4.
Tong XJ, Hirai K, Shimada H et al (1994) Sciatic nerve regeneration navigated by
laminin-fibronectin double coated biodegradable collagen grafts in rats, Brain Res
663:155–62.
Tos P, Battiston B, Geuna S et al (2000) Tissue specificity in rat peripheral nerve
regeneration through combined skeletal muscle and vein conduit grafts, Microsurgery
20:65–71.
Valentini RF, Aebischer P, Winn SR et al (1987) Collagen- and laminin-containing gels
impede peripheral nerve regeneration through semipermeable nerve guidance
channels, Exp Neurol 98:350–6.
Valero-Cabré A, Tsironis K, Skouras E et al (2001) Superior muscle reinneravtion after
autologous nerve graft or poly-1-lactide-ε-caprolactone (PLC) tube implantation in
comparison to silicone tube repair, J Neurosci Res 63:214–23.
Wang GY, Hirai K, Shimada H et al (1992) Behavior of axons, Schwann cells and
perineurial cells in nerve regeneration within transplanted nerve grafts: effects of anti-
laminin and anti-fibronectin antisera, Brain Res 283:216–26.
Weber RA, Breidenback WC, Brown RE et al (2000) A randomised prospective study of
polyglycolic acid conduits for digital nerve reconstruction in humans, Plast Reconstr
Surg 106:1036–45.
Whitworth IH, Brown RA, Dore CJ et al (1995a) Orientated mats of fibronectin as a
conduit material for use in peripheral nerve repair, J Hand Surg 20B:429–36.
Whitworth IH, Terenghi G, Green CJ et al (1995b) Targeted delivery nerve growth factor
via fibronectin conduits assists nerve regeneration in control and diabetic rats, Eur J
Whitworth IH, Dore CJ, Green CJ et al (1995c) Increased axonal regeneration over long
nerve gaps using autologous nerve-muscle sandwich grafts, Microsurgery 16:772–8.
Whitworth IH, Brown RA, Dore CJ et al (1996) Nerve growth factor enhances nerve
regeneration through fibronectin grafts, J Hand Surg 21B:514–22.
Wiberg M, Ljungberg C, O’Byrne A et al (1999) Primary sensory neuron survival
following targeted administration of NGF to an injured nerve, Scand J Plast Reconstr
Hand Surg 33:387–92.
Williams LR (1987) Exogenous fibrin matrix precursors stimulate the temporal progress
of nerve regeneration within a silicone chamber, Neurochem Res 12:851–60.
Wu S, Suzuki Y, Tanihara M et al (2002) Repair of facial nerve with alginate sponge
without suturing: an experimental study in cats, Scand J Plast Reconstr Surg Hand
Surg 36:135–40.
Xiao-Lin L, Lundborg G, Dahlin LB et al (2001) Use of chemically extracted muscle
grafts to repair extended nerve defects in rats, Scand J Plast Reconstr Hand Surg
35:1–9.
Yoshii S, Oka M, Ikeda N et al (2001) Bridging a peripheral nerve defect using collagen
filaments, J Hand Surg (Am) 26:52–9.
Yoshii S, Oka M, Shima M et al (2002) 30 mm regeneration of rat sciatic nerve along
collagen filaments, Brain Res 949:202–8.
Young RC, Wiberg M, Terenghi G (2002) Poly-3-hydroxybutyrate (PHB): a resorbable
conduit for long-gap repair in peripheral nerves, Br J Plast Surg 55:235–40.
Zamboni WA, Brown RE, Roth AC et al (1995) Functional evaluation of peripheral-
nerve repair and the effect of hyperbaric oxygen, J Reconstr Microsurg 11:27–9.
Zeng L, Worseg A, Albrecht G et al (1995) Bridging of peripheral nerve defects with
exogenous laminin-fibrin matrix in silicone tubes in a rat model, Restor Neurol
Zhao Q, Dahlin LB, Kanje M et al (1993) Repair of the transected rat sciatic nerve:
matrix formation within silicone tubes, Restor Neurol Neurosci 5:197–204.
15
End-to-side neurorrhaphy: an alternative
method for reinnervation in cases with long
nerve defects
Manfred Frey and Pietro Giovanoli
Introduction
The results of surgical reconstruction by proximal nerve repair or with long nerve grafts
are often not satisfying clinically. Recovery of motor and sensory function depends on a
critical number of axons reaching the target organ and on reinnervating muscle fibres and
sensory receptors within a critical period after denervation. In limited cases, like in
avulsion injuries, where no donor nerve or nerve transfer is available for direct end-to-
end suture, or in cases where extremely long distances have to be overcome by the
regenerating axons and limited functional results are to be expected, end-to-side suture of
the distal part of the injured nerve to an uninjured nerve in the neighbourhood may offer a
practical solution.
The technique of end-to-side neurorrhaphy was first used by Depres in 1876, in a
median nerve injury. He inserted the distal portion of the nerve between the fibres of the
ulnar nerve, as reported by Sherren (1906). At the beginning of the twentieth century
several reports of clinical application followed. Ballance et al (1903) published their
experience with end-to-side neurorrhaphy in the operative treatment of chronic facial
palsy of peripheral origin. In the same year Harris and Low (1903) reported on cross-
unions of nerve roots to treat Erb’s palsy and infantile paralysis of the upper extremity.
Kennedy discussed as early as in 1901 the interchange of function of the cerebral cortical
centres during restoration of coordinated movement after nerve crossing. He sutured the
distal end of the facial nerve end-to-side into the accessory nerve dividing a significant
part of this nerve. At that time partial neurotomy of the donor nerve caused significant
morbidity and the clinical outcome of end-to-side neurorrhaphy was below an acceptable
limit. This technique of nerve reconstruction was forgotten until the early 1990s, when
Viterbo (Viterbo et al 1992, 1994a,b) reported on a successful experimental series in rats.
This optimistic revival of the end-to-side nerve suture stimulated many international
centres to perform research work predominantly in the rat and to develop experience in
clinical application. In the past 10 years almost 40 scientific papers have been published,
the majority being experimental studies. The few clinical publications are limited to case
reports that are usually poorly documented. Over all, the majority of authors conclude
that end-to-side neurorrhaphy is a successful tool for reinnervation: experimentally and
clinically.
Our research group studied end-to-side neurorrhaphy in rabbits, a larger animal more
comparable to human conditions, and reported excellent functional results without
downgrading the donor nerve (Giovanoli et al 2000). Besides this, detailed nerve fibre
distribution was studied for the first time in all cross-sections on different levels:
proximal, within and distal to the end-toside nerve suture. We found that the regenerative
stimulus of the distal nerve segment is not limited to the contact zone. These results as
well as the technique used, that is fenestrating the epineurium and leaving the
perineurium intact, was of important influence on our clinical work. In this chapter we
report that end-to-side neurorrhaphy achieves clinically efficient results and that, on the
basis of this reliability, end-to-side neurorrhaphy for reinnervation of a free functional
muscle transplant is justified in selected cases.
Methods
Since our first clinical end-to-side neurorrhaphy in a replantation case of an avulsed

thumb on 9 September 1995, we have used end-to-side nerve repair for motor or sensory
reinnervation in the upper extremities of nine patients (Table 1). In three patients primary
nerve repair using end-toside neurorrhaphy was performed in an avulsion injury of a
finger (n = 2) or in a replantation at upper arm level (n = 2). In three brachial plexus
reconstructions end-to-side nerve repair was used after tumour resection. A free
functional muscle graft was reinnervated by an end-to-side neurorrhaphy in three patients
after tumour resection (n = 1) and Volkmann’s contracture (n = 1) and in a brachial
plexus lesion (n = 1).
Surgical technique
Having identified the distal nerve stump and missing corresponding proximal nerve
stump usually because of avulsion trauma to the nerve, end-to-side neurorrhaphy is
indicated as primary nerve repair. A synergistic nerve next to the distal nerve stump is
selected for end-to-side nerve suture. This is important for a clinically useful result,
because antagonistic co-contractions would limit the regained function in the case of
motor reinnervation, and sensory perception would be difficult to be re-localized from a
completely different dermatome. A window of similar size to the cross-section of the
distal nerve stump is cut into the epineurium of the donor nerve with microsurgical
technique under the microscope. Trauma to the nerve fibres themselves should be kept to
a minimum. In our opinion traumatic preconditioning is not a presupposition for adequate
sprouting of the nerve fibres into the distal nerve segment brought in end-to-side contact.
The epineurium of the distal stump is sutured to the margins of the epineurial window
using four to six 10-0 nylon interrupted sutures. If mixed stem nerves are used as donors,
known dominance of motor or sensory fibres in the different fascicles of the thicker nerve
is considered corresponding to the target to be reinnervated; especially in multifascicular
nerves this may be more important than in a monofascicular nerve branch. Intraoperative,
selective electric stimulation is very helpful to localize fascicles containing
predominantly motor fibres along the circumference of the nerve and to identify the
muscle or muscle group reacting. Trains of pulses with a low amplitude of 1–2 mA are
used for submaximal stimulation (Neurostimulator, Aesculap® type GN 015).
End-to-side neurorrhaphy 211
In the case of irreversible loss of the muscle target by direct trauma, ischaemia,
tumour resection or irreversible atrophy as a consequence of longstanding paralysis,
replacement of the muscle target has to be performed by free muscle transplantation with
microneurovascular anastomoses. If this problem is combined with that of a missing
proximal source for reinnervation, end-to-side neurorrhaphy of the muscle nerve to a
synergistic intact or sufficiently regenerated donor nerve is indicated.
Distal end-to-side neurorrhaphy of a nerve graft to a nerve with some remaining
function may be useful for reinforcement of clinically insufficient muscle function. If this
technique does not result in an acceptable functional improvement, the distal end of the
nerve graft can still be used for an additional muscle transplant with end-to-end nerve
suture. So far, we have used this technique in two cases of incomplete facial paralysis,
but not in the upper extremity.
Results
Sensory recovery was obtained in the two patients with lesions of a digital nerve. The
static two-point discrimination was 3.0 mm and the dynamic two-point discrimination
was 2–3 mm in the areas of the fingers reinnervated by the endto-side neurorrhaphy,
compared to 2 mm for static and dynamic two-point discrimination in the area supplied
by the ‘donor’ nerve. The stem of the median nerve served as a donor for the ulnar side of
the replanted thumb of a 12-yearold girl (Fig. 1), and the radial finger nerve for the
avulsed ulnar finger nerve in a 42-year-old man after a circular saw injury.
Table 1 Clinical cases of end-to-side neurorrhaphy in the upper limb.

Patient Age Sex Diagnosis (lesion) Reconstruction Follow- Result
number (years) up
(months)
1 12 F Avulsion/amputation Replantation, end-to- 48 Static 2-point
left thumb side neurorrhaphy of discrimination
avulsed ulnar digital 3 mm
nerve to median nerve Dynamic 2-
point
discrimination
2–3 mm
2 42 M Avulsion right ring Revascularization, 37 Static 2-point
finger end-to-side discrimination
neurorrhaphy of 3 mm
avulsed ulnar to radial Dynamic 2-
digital nerve point
discrimination
2–3 mm
3 10 M Amputation left Replantation, end-to- 18 Protective
upper arm, avulsion side neurorrhaphy of sensibility in
roots C8 and T1, lower trunk to root all fingers, no

comminuted fracture C7, open reduction, motor function
left forearm internal fixation
radius and ulna
4 43 M Soft tissue sarcoma Resection/amputation, 8 Progression
proximal right upper replantation by Tinel sign to
arm shortening elbow level,
patient died 11
months
postoperatively
from lung
metastases
5 34 F Recurrence of Resection (including 4 Time since
malignant nerve root T1), soft tissue reconstruction
sheath tumour right reconstruction using too short for
thoracic wall latissimus dorsi clinical signs
myocutaneous flap, of
end-to-side reinnervation
neurorrhaphy root T1
to C8
6 41 F Chondrosarcoma Resection, including 3 Time since
right humeral head posterior cord and reconstruction
musculocutaneous too short for
nerve; anatomic clinical signs
reconstruction of of
posterior cord and reinnervation
motor branch to
biceps muscle (nerve
grafts), end-to-side
neurorrhaphy lateral
cutaneous
antebrachial nerve to
median nerve
7 28 M Osteosarcoma left Resection, elbow joint 29 Wrist and
elbow prosthesis, latissimus finger
dorsi extension M3–
musculocutaneous 4
flap for soft tissue
coverage and to
reconstruct wrist and
finger extension, end-
to-side neurorrhaphy
of muscle nerve to
radial nerve
Patient Age Sex Diagnosis Reconstruction Follow- Result
number (years) (lesion) up
(months)
8 29 F Longstanding Free functioning 13 Thumb
brachial plexus gracilis muscle and finger
lesion right side transfer to reconstruct flexion
(part, C7, finger flexion, end-to- M3
avulsion C8/T1) side neurorrhaphy of
muscle nerve to
median nerve (branch
to pronator muscle)
9 32 M Volkmann’s Free functioning 38 Excellent
contracture left latissimus dorsi wrist and
forearm muscle transfer to finger
reconstruct wrist and flexion
finger flexion, end-to- (M4)
side neurorrhaphy to
median nerve,
neurolysis of median
nerve
Figure 1
Sensory reinnervation of the ulnar pulp of a replanted
thumb by end-to-side neurorrhaphy of the avulsed finger
nerve to the median nerve in a 12-year-old girl. (a)
Amputation of the left thumb by the bridle while falling
from the back of a horse. (b) Full functional recovery 4
years after replantation (c). Ninhydrin test shows good
recovery of sudomotor function on both sides of the
replanted left thumb (right finger print), compared to the
normal right thumb (left finger print). (d) Potential
deducted after electric stimulation at the ulnar side of the
thumb (R4, orthodromic sensory conduction of finger
nerves, stimulus application to the finger nerves
percutaneously, recording at the wrist, 16 signals
averaged) shows good sensory nerve function equal to the
result after reinnervation by end-toend suture of the radial
thumb nerve (R2).
Because of the extremely long distances involved in the nerve regeneration, the results of
two of the patients are not available 8 months and 18 months after replantation at the
upper arm level. In both the replanted arms progression of the Tinel sign has been
observed, and in the case of the 10-year-old boy useful sensory and motor reinnervation
could be observed 18 months after replantation. In major limb replantations and in cases
of reconstruction of the brachial plexus it is difficult to identify the part of reinnervation
resulting from end-to-side neurorrhaphy through the avulsed roots of the plexus, if end-
to-end coaptation of disrupted parts of the plexus has been performed at the same time.
However, the patients did not suffer any disadvantages by the additional end-to-side
neurorrhaphies.
One latissimus dorsi myocutaneous flap for functional reconstruction after tumour
resection—end-to-side to the radial nerve for improvement of elbow, wrist and finger
extension
Figure 2(a–d)
Figure 2(e–h)
Reconstruction, with soft tissue coverage of an elbow
prosthesis and of motor function for elbow, wrist and
finger extension, by a free myocutaneous latissimus dorsi
flap with end-to-side neurorrhaphy of the thoracodorsal
nerve to the radial nerve. (a) Soft tissue deficit at the left
elbow in a 22-year-old man, who had a radical resection of
an osteosarcoma and implantation of an elbow prosthesis.
(b) The extensor function was not enough to extend the
elbow against weight or to open the hand for grip
(maximal extension). (c) Myocutaneous latissimus dorsi
flap with the neurovascular anastomoses completed (white
loop around the radial nerve). (d) Detail of the end-to-side
neurorrhaphy of the muscle nerve to the radial nerve. (e,f)
Good soft tissue coverage of the left elbow and good
extensor function at the elbow, wrist and fingers 2 years
after the operation. (g,h) Significant improvement of the
extensor function with opening of the hand for the grip.
(Fig. 2)—resulted in a clinically useful function with contraction against gravity and
resistance graded M3 to M4 (muscle power graded M0-M5 using the Highet scale
adopted by the British Medical Research Council, Tubiana and Masquelet, 1988). Hence
a functional upgrading of the region of tumour resection could be achieved besides a
stable soft tissue coverage.
The gracilis muscle transplant in a 32-year-old woman and the latissimus dorsi muscle
transplant in a 28-year-old man (Fig. 3), both reinnervated by end-to-side neurorrhaphy to
the median nerve showed good restoration of finger flexion after complete loss by
Volkmann’s contracture (M3 and M4).
Discussion
Our growing experience with the clinical application of end-to-side neurorrhaphy shows
clearly that this technique is reliable and clinically useful results can be expected for
motor as well as for
Figure 3
Successful reinnervation of a myocutaneous latissimus
dorsi flap in a 32-year-old man by end-to-side
neurorrhaphy. (a) Ischaemic contracture of the left lower
arm, the fingers fixed in a severe flexion contracture. (b,c)
2 years after muscle transplantation and endto-side suture

of the thoracodorsal nerve of the muscle graft to the
median nerve. The blockade of extension had been
removed (b), and strong finger flexion became possible by
a well contracting muscle transplant (c). Reproducible,
polyphasic motor unit potential and stable late component
corresponding to a reinnervation potential in an MNC
record of the transplanted muscle reinnervated by end-to-
side neurorrhaphy. Duration 27 msec, amplitude 360 µV,
latency for 10 cm between stimulation site at the median
nerve and recording site 2.8 msec.
sensory reinnervation. Considering the fact that we have been using end-to-side
neurorrhaphy so far in situations where a proximal nerve stump was not available for
nerve reconstruction, the results obtained mean a significant improvement of the overall
functional outcome of nerve reconstructions. This additional option is going to change
fundamentally the concepts of recon structive surgery of the peripheral nerves (Frey et al
1998) and broadening the indications for end-to-side neurorrhaphy might show results
that compete with end-to-end coaptation or endto-end nerve graft interpositioning.
In literature, the reported results of the end-toside neurorrhaphy vary between
complete failure (Kayikcioglu et al 2000) and excellent reinnervation (Franciosi et al
1998, Kostakoglu 1999, Mennen 1999, Rapp et al 1999, Yoleri et al 2000). The majority
of reports are now positive. Yoleri et al (2000) performed end-to-side neurorrhaphy of the
facial nerve to the hypoglossal nerve in four patients with varying success. Sensory
reinnervation by end-to-side neurorrhaphy of the palmar digital nerves of thumb and
index finger to the superficial branch of the radial nerve could be achieved by Rapp et al
(1999) This study also includes cases with end-to-end suture of the donor and recipient
nerves, and did not show superiority of the end-to-end technique compared to the end-to-
side technique. In contrast, Santamaria et al (1999) found better results by end-to-end
nerve suture compared to end-to-side nerve suture, when they connected the sensory
nerve of the radial forearm flap to the lingual nerve. Some useful protective sensibility is
reported for a median nerve by Kostakoglu (1999), when the distal part was put end-to-
side to the ulnar nerve because of a 35 cm defect in the median nerve. The positive role
of end-toside nerve reconstructions in brachial plexus lesions is difficult to evaluate in the
overall functional end result. When Viterbo et al (1995) described a promising case of
brachial plexus reinnervation by nerve grafts sutured end-to-side to the phrenic nerve and
end-to-end to C5 and C6 in 1995, Dellon (1996) criticized the unscientific follow-up of
this case report. In the meantime, the number of publications on successful applications
of the end-to-side neurorrhaphy in brachial plexus reconstructions continues to grow
(Franciosi et al 1998, Mennen 1999).
Although some important questions on endto-side neurorraphy can be answered by
several experimental studies, many questions remain: How does the end-to-side
neurorrhaphy function? Is an epineurial window enough, or could better results be
obtained by cutting a perineurial window? What are the decisive factors during the
selection of the donor nerve? What is the role of the target? And is the spinal cord level
of the donor and the recipient nerve of any importance?
Our own experimental studies (Giovanoli et al 2000) showed that end-to-side

neurorrhaphy is accompanied by a significant increase of the total number of the
peripheral donor nerve fibres. The end-to-side contact seems to be a strong stimulus for
collateral sprouting in the area of the end-to-side nerve suture. Because the number of
nerve fibres remained constant in the distal donor nerve segment and there was no
functional deficit measured in the muscles innervated by the donor nerve, in our opinion,
retraction of the donor nerve fibres from their targets is not a precondition for a
successful functional contact of the sprouting fibre with its new and additional target. Our
findings are supported by Kanje et al (2000) who showed double-labelled sensory and
motor neurons after end-to-side suture. This indicated that collateral sprouting was
induced by a nerve segment sutured end-toside to the intact rat sciatic nerve. Tham and
Morrison (1998) considered the severed proximal nerve as a source for fibre growth into
the endto-side connection. This mechanism might be relevant in our clinical cases with
avulsed nerves, but the aim of an excellent clinical result was met anyway, independently
from the origin of the regenerating fibres.
Cutting a perineurial window means trauma to at least some of the nerve fibres of the
donor nerve and should ideally be prevented. From our experimental studies as well as
from clinical experience we know that an epineurial window is satisfactory and
preservation of the perineurium does not prevent acheivement of excellent results with
end-to-side nerve suture. A comparative study of Viterbo et al (1998) did not show any
difference between the two techniques, although Okajima and Terzis (2000) and al-
Quattan and al-Thunyan (1998) stress the necessity of a perineurial window.
In experimental studies in rats Lutz et al (2000a) demonstrated the importance of the
preference of agonistic nerves as donors to prevent co-contractions. The authors could
show that concentration of end-to-side reinnervation to a single muscle is more effective
than reinnervation of a group of different muscles (Lutz et al 2000b). Their experimental
findings correlate well with our clinical experience (Frey et al 1998, Frey 2000).
Further considerations arise from the results of an experimental study of Zhang et al
(1998) They showed that end-to-side neurorrhaphy is unsuccessful if donor and recipient
nerves are originating at different spinal cord levels.
Further possibilities for clinical application of the end-to-side nerve suture were
presented by Viterbo et al in 2000 in cross-face nerve grafting with end-to-side
neurorraphy on the healthy and the paralysed side. Improvement of mimic function in
nine of 10 cases is difficult to believe, if one considers the fact that all patients suffered
from a palsy lasting more than 1 year which can be rarely reanimated by the end-to-end
cross-face nerve grafting technique without the need of an additional free muscle
transplant. A further group of 14 patients showed some successful recovery of sensory
function after an ‘embracing suture’ of the rectus abdominis nerve to the fourth
intercostal nerve during breast reconstruction with a TRAM flap. Fifty per cent of the
patients achieved a reasonable degree of sensation in the flap. Finally the authors reported
a case of successful reinnervation of the sacral region in a paraplegic patient by nerve
grafts connected end-to-side to the eleventh intercostal nerve.
We could include the results of three patients after motor reconstruction by a free
functional muscle transplant reinnervated by end-to-side neurorrhaphy in this chapter. To
our knowledge, this is the first report on the clinical application of end-to-side
neurorrhaphy for reinnervation of a free muscle transplant. In one case radical tumour
resection included a functional group of muscles leaving a nerve with some peripheral
function behind. Two other patients had lost the majority of flexor function in the lower
arm by ischaemic contracture. The remaining function was not clinically relevant (M2),
but should certainly not be reduced by the operation. We used end-to-side neurorrhaphy
to the main trunk of the nerve originally responsible for the absent motor function. By
that we could retain the remaining partial motor and sensory function of the nerve.
Combining muscle transplantation with end-to-side neurorrhaphy the motor function was
upgraded in all three patients. Having achieved a clinically relevant motor function of M3
or M4 in all muscle transplants and having done no harm to any of the donor nerves, we
are thinking of using the end-to-side technique more frequently for reinnervation of a
muscle graft.
Conclusions
Although the indications for the end-to-side nerve suture are still limited to cases with
otherwise poor prognosis, these are described more clearly:
• Proximal avulsion leaving the main nerve trunk in continuity.
• Missing proximal nerve stumps.
• Partial recovery after nerve reconstruction.
• Shortening of long distances necessary to be covered by the regenerating nerve axons.
• Prevention of long nerve grafts in proximal lesions.
• Functional muscle transplantation.
The degree of restoration of motor or sensory function by end-to-side neurorrhaphy
depends on some crucial factors like selection of the proper agonistic donor nerve,
minimizing donor nerve trauma by cutting only an epineurial window into the nerve, and
an attempt to be highly selective with respect to sensorimotor and topographic
differentiation.
The results of our study show that end-to-side neurorrhaphy is an efficient method of
motor or sensory reinnervation. Especially, this technique is reliable in combination with
a free functional muscle transplantation and leads the way for new possibilities for
neuromuscular reconstruction even in cases when useful function cannot be achieved by
nerve reconstruction alone.
Acknowledgements
The authors wish to thank Dr Doris Burg, neurologist at the Division of Reconstructive
Surgery at the University Hospital at Zurich, and Dr Tatjana Paternostro-Sluga, specialist
in electroneurodiagnostic follow-up studies, at the Department of Physical Medicine and
Rehabilitation at the University of Vienna, for their detailed electroneurodiagnostic
studies in our patients. Through their work an objective evaluation of the results of end-
to-side neurorrhaphy became possible independently from the surgeons treating the
patients. Mag Susanne Friedl was very helpful in preparing the manuscript, for which we
would like to thank her.
Our research work on experimental muscle transplantation using end-to-side

neurorrhaphy was possible because of the sponsorship of the Oesterreichische
Nationalbank (Grant Number 7791).
The laboratory for picture and movement analysis at our department is dedicated to
objective evaluation of regained motor function after reconstructive surgery. Our work is
supported by a generous research grant by the Austrian Federal Ministry of Education,
Science and Culture (Project Number GZ 308.974/4-III/2a99), for which we are most
grateful. This grant supports multicentre studies and further developments within the
International Registry for Neuromuscular Reconstruction in the Face.
References
al-Qattan MM, al-Thunyan A (1998) Variables affecting axonal regeneration following

end-to-side neurorrhaphy, Br J Plast Surg 51:238–42.
Ballance CA, Ballance HA, Stewart P (1903) Remarks on the operative treatment of
chronic facial palsy of peripheral origin, BMJ 1:1009.
Dellon AL (1996) Nerve grafting and end-to-side neurorrhaphies connecting phrenic
nerve to the brachial plexus, Plast Reconstr Surg 98:905.
Franciosi LF, Modestti C, Mueller SF (1998) Neurotization of the biceps muscle by end-
to-side neurorrhaphy between ulnar and musculocutaneous nerves. A series of five
cases, Chir Main, 17:362–7.
Frey M (2000) Avulsion injuries to the brachial plexus and the value of motor
reinnervation by ipsilateral nerve transfer, J Hand Surg (Br) 25:323–4.
Frey M, Girsch W, Giovanoli P (1998) [Possibilities for reconstruction in brachial plexus
paralysis: neurotization], Langenbecks Arch Chir Suppl Kongressbd 115:550–3.
Giovanoli P, Koller R, Meuli-Simmen C et al (2000) Functional and morphometric
evaluation of end-to-side neurorrhaphy for muscle reinnervation, Plast Reconstr Surg
106:383–92.
Harris W, Low VW (1903) On the importance of accurate muscular analysis in lesions of
the brachial plexus; and treatment of Erb’s palsy and infantile paralysis of the upper
extremity by cross-union of the nerve roots, BMJ 2:1035.
Kanje M, Arai T, Lundborg G (2000) Collateral sprouting from sensory and motor axons
into an end-to-side attached nerve segment, Neuroreport 11:2455–9.
Kayikcioglu A, Karamursel S, Agaoglu G, Kecik A, Celiker R, Cetin A (2000) End-to-
side neurorrhaphies of the ulnar and median nerves at the wrist: report of two cases
without sensory or motor improvement, Ann Plast Surg 45:641–3.
Kennedy R (1901) On the restoration of coordinated movement after nerve crossing, with
interchange of function of the cerebral cortical centers, Philos Trans R Soc Lond B
Biol Sci 194:127.
Kostakoglu N (1999) Motor and sensory reinnervation in the hand after an end-to-side
median to ulnar nerve coaptation in the forearm, Br J Plast Surg 52:404–7.
Lutz BS, Chuang DC, Hsu JC, Ma SF, Wei FC (2000a) Selection of donor nerves—an
important factor in endto-side neurorrhaphy, Br J Plast Surg 53:149–54.
Lutz BS, Ma SF, Chuang DC, Wei FC (2000b) Role of the target in end-to-side
neurorrhaphy: reinnervation of a single muscle vs multiple muscles, J Reconstr
Mennen U (1999) End-to-side nerve suture—a technique to repair peripheral nerve
injury, S Afr Med J 89:1188–94.
Okajima S, Terzis JK (2000) Ultrastructure of early axonal regeneration in an end-to-side
neurorrhaphy model, J Reconstr Microsurg 16:313–23; discussion 323–6.
Rapp E, Lallemand S, Ehrler S, Buch N, Foucher G (1999) Restoration of sensation over
the contact surfaces of the thumb-index pinch grip using the terminal branches of the
superficial branch of the radial nerve, Chir Main 18:179–83.
Santamaria E, Wei FC, Chen IH, Chuang DC (1999) Sensation recovery on innervated
radial forearm flap for hemiglossectomy reconstruction by using different recipient
nerves, Plast Reconstr Surg 103:450–7.
Sherren J (1906) Some points in the surgery of peripheral nerves, Edinb Med J 20:297.
Tham SK, Morrison WA (1998) Motor collateral sprouting through an end-to-side nerve
repair, J Hand Surg (Am) 23:844–51.
Tubiana R, Masquelet AC (1988) Functional classification of the upper limb paralyses,
Hand Clin 4:557–62.
Viterbo F, Trindade JC, Hoshino K, Mazzoni Neto A (1992) Latero-terminal
neurorrhaphy without removal of the epineurial sheath. Experimental study in rats,
Rev Paul Med 110:267–75.
Viterbo F, Trindade JC, Hoshino K, Mazzoni A (1994a) Two end-to-side neurorrhaphies
and nerve graft with removal of the epineural sheath: experimental study in rats, Br J
Viterbo F, Trindade JC, Hoshino K, Mazzoni Neto A (1994b) End-to-side neurorrhaphy
with removal of the epineurial sheath: an experimental study in rats, Plast Reconstr
Surg 94:1038–47.
Viterbo F, Franciosi LF, Palhares A (1995) Nerve graftings and end-to-side
neurorrhaphies connecting the phrenic nerve to the brachial plexus, Plast Reconstr
Surg 96:494–5.
Viterbo F, Teixeira E, Hoshino K, Padovani CR (1998) End-to-side neurorrhaphy with
and without perineurium, Rev Paul Med 116:1808–14.
Viterbo F, Sanches J, RW (2000) In: Frey M, Giovanoli P, Koller R, eds. Fifth
International Muscle Symposium. Vienna, pp. 151.
Yoleri L, Songur E, Yoleri O, Vural T, Cagdas A (2000) Reanimation of early facial
paralysis with hypoglossal/facial end-to-side neurorrhaphy: a new approach, J
Reconstr Microsurg 16:347–55; discussion 355–6.
Zhang F, Cheng C, Chin BT et al (1998) Results of termino-lateral neurorrhaphy to
original and adjacent nerves, Microsurgery 18:276–81.
Tendon defect repair
16
Conventional tendon grafting
Antonio Landi, Giuseppe Caserta, Norman Della Rosa and Andrea Leti
Acciaro
History
A clear distinction between tendons and nerves was made at the end of the nineteenth
century. In ancient Greek culture the word ‘neuron’ was attributed both to nerves and to
tendons and its heritage might occasionally explain why, even in contemporary times,
tendons might be erroneously connected to nerves in the emergency setting.
Apparently Heuck (1881), a general surgeon, was the first to perform a tendon graft to
repair the extensor pollicis longus (EPL). Soon after, at the Surgical Society of Paris,
Peyrot (1886) reported a case of ‘transplantation’ of a tendon of a dog in a man to replace
the flexor tendon of the middle finger. The related experimental work was extensively
carried out in Germany at the beginning of the twentieth century by Lange (1900). Mayer
(Mayer 1916a–c, Mayer and Ransohoff 1936), who had worked in Munich under the
supervision of Lange, published several articles on tendon transplantation. His clinical
experience was mainly confined to the lower limbs and the corresponding pioneering
work on the upper limb was initiated by Sterling Bunnell in San Francisco and
summarized in his first article on tendon repair in fingers published in 1918 (Bunnell
1918).
Tendon allografts have been routinely used in Europe by Iselin (1975) and by several
European surgeons who had their training in Nanterre. For many years, in fact, Iselin has
advocated the use of acellular grafts preserved in a mercurial solution of 1 g of Cialit in 5
l of sterile water (Iselin 1975, Tubiana 1997). This technique maintained its popularity
for quite a long while and was finally banned within the Common Market of the
European Community.
Reconstruction of the pseudo-sheath in presence of severe tendon damage is based on
the earlier work of Biesalski (1910). Mayer and Ransohoff (1936) used celloidin tubes as
implants and stainless steel implants were introduced by Milgram (1960); Carrol and
Bassett (1963) were able to show that a flexible silicone rubber rod could be safely
implanted in a scarred tendon bed to reconstruct the flexor tendons of the hand.
In the early 1950s tendon grafting was the elective procedure for flexor tendon lesions
in ‘no-man’s land’ as a consequence of relinquishment to proceed to primary repair
within this anatomical boundary. Bunnell’s (1918) advice to close the skin, wait for the
wound to heal, and then perform secondary grafting become a dogma for generations of
surgeons (Graham 1947, Littler 1947, Boyes 1950, Pulvertaft 1956, Tubiana 1960). The
state of the art of this commonly shared surgical attitude was summarized in the
outstanding presentation delivered by JH Boyes on February 15, 1950 at the American
Academy of Orthopedic Surgeons in New York (Boyes 1950). Out of a total of 138
Conventional tendon grafting 225
grafts, although nearly 90% of the cases in the ‘good’ group achieved flexion to within
one inch of the distal palmar crease, less then half of those having stiff joints and only a
quarter of the ‘cicatrix’ group obtained such a good degree of flexion (Boyes 1997).
Technical advancement would soon also improve the outcome even in these less
favourable groups.
In 1965, and later in 1971 along with Salisbury, Hunter first published his personal
experience with a tendon implant (Hunter and Salisbury 1971, Schneider 1997a,b). In a
staged technique the severely damaged flexor tendons were excised and the flexor
apparatus reconstructed with a new sheath prepared around a silicone Dacron reinforced
implant. This paper is considered a milestone in the field of flexor tendon reconstruction,
and the corresponding procedure has thereafter been universally attributed to Hunter.
The pedicled tendon graft was described by Paneva-Holevich from Sofia in 1965
(Paneva 1987). This procedure was apparently first done in Bulgaria in April 1964 in a
male patient with a complex lesion involving the skin and flexor apparatus of the index
and middle fingers. Skin coverage was accomplished by a pedicled flap and the proximal
stump of superficial and profundus flexor tendons were sutured to each other. Two
months later the superficialis flexor tendon was transferred as a pedicled graft to replace
the sublimis function whilst fusing the distal interphalangeal (DIP) joint. The same
technique had already been extensively used by DM Brooks at the Royal National
Orthopaedic Hospital in London, but was never published.
The Hunter active tendon prosthesis, which allows the transformation of a two-stage
technique into a potentially one-stage technique, might be considered a further step
forward, but it has not gained sufficient acceptance and consensus for any conclusions to
be drawn (Hunter and Salisbury 1997, Hunter et al 1997). A further attempt to reduce the
length of a staged procedure was made by the introduction of the vascularized tendon
graft, which is not adversely influenced by the unfavourable condition of the recipient
bed and might therefore be utilized as a single stage procedure.
Repair of flexor tendon defects
Severe post-traumatic defects of tendons are usually associated with complex lesions in
the upper limb. Preliminary ancillary interventions on skin or contiguous anatomical
structures (bones, joints) have usually been anticipated to attempt, at a later stage, to re-
establish the active motion of the finger (Landi et al 1997 a,b, 2002). Secondary
reconstruction is also indicated when primary tendon repair has failed or has been
delayed due to infection (Bishop et al 1996). Exposure of the tendon per se has
detrimental effects on tendon metabolism and adds to the risk of contamination (Landi
1973).
Clinical examination of the affected hand is mandatory as, in presence of still
unresolved problems (neuroma, sensation deficit, joint stiffness), adequate treatment prior
to tendon grafting is essential. Furthermore, the nature of the associated joint contracture
(flexion or extension contracture) has to be clearly defined. In fact, one might have to
deal with stiffness in the presence of a radiologically preserved single joint, derangement
of a limited sector of one joint surface, derangement of an entire joint surface, or
complete disruption of the joint. The presence of joint stiffness will deeply influence
further decisions (Landi et al 1997b, 2002).
In the presence of irreversibly damaged DIP joint, reconstruction of the flexor
digitorum profundus is unnecessary and the flexor superficialis finger should be
considered as a salvage procedure (Schneider et al 1987).
Prerequisites
Fractures need to be well reduced and healed, and non-union already treated with
restoration of passive mobility of digital joints before tendon grafting can be considered
(Bishop et al 1996, Landi et al 1997a).
Circulation must be adequate, even more so when profundus tendon grafting is to be
carried out in replanted fingers or hands. Before the operation it is advisable to obtain a
Doppler study on the patency of the sutured vessels. Moreover, the original surgical notes
must be carefully consulted, any available drawings examined and particular attention
paid to ascertain if vessel shifting has been carried out (Landi et al 1985, 1997a). Flexor
tendon grafting in replanted fingers that have had vascular complications but finally
survived, usually do not have favourable outcomes (Landi et al 1985). Sensation must be
adequate and at least one digital nerve must have been repaired. Neuroma must be treated
by conventional nerve or interposed vein grafting as a painful digit will poorly exploit
restored mobility.
Flexion deformity of the proximal interphalangeal (PIP) joint and
metacarpophalangeal (MP) joint or at the wrist joint level might be caused by both
intrinsic and extrinsic factors. A fixed deformity might be caused by soft tissue
contracture due to thermal injury or a deep infection following flexor tendon repair. Joint
release before tendon grafting can result in a skin defect. Therefore, the surgical approach
to the extrinsic or intrinsic structures of a joint varies according to the condition of the
overlying skin. In the presence of hypomobile skin, or longitudinally contracted skin a Z
plasty or V–Y advancement flap is sufficient (Landi et al 1997a,b, 2002). When a skin
gap ≥1 cm is anticipated a lateral transposition flap is often sufficient (Bruser et al 1999).
In more extensive skin defects we tend to select the flap described by Malek or a similar
version described by Kleinman (1996). Cross-finger flaps, or flaps from the neighbouring
digits are only performed in the presence of a significant skin defect when a volar release
has to precede a staged flexor tendon reconstruction. Flexion deformity of the MP joint,
when caused by skin scarring or contracture, in most cases can be treated with full
thickness skin grafts. When subcutaneous padding is absent a flap must be considered.
We agree with Foucher (1997) that there is no standard flap for the palm which
provides a supple and thin skin. A fascial flap plus grafting might be a reasonable
compromise. Flexion contracture at the wrist usually requires release and coverage by a
regional, axial flap (based on perforator flap) or a free flap (Landi et al 1980b).
The level of injury of the flexor tendons is also important (Fig. 1). Flexor tendon
grafting might be performed for injuries which have occurred from zone I (the area distal
to the insertion of the flexor digitorum superficialis (FDS)) to zone V, where the main
nerves and feeding vessels to the hand are concentrated.
Age and compliance with postoperative rehabilitation are also crucial. In younger
patients any secondary procedure on the tendon should be postponed until the child is
capable of playing a more active role (Bishop et al 1996, Osterman and Paksima 1997).
The best results are obtained between the ages of 10 and 30 years (Bishop et al 1996,
Boyes 1997). In our view, flexor tendon grafting is therefore not indicated under the age
of 10 years with the exception of the FPL.
Figure 1
Classification of cases
In order to select the most appropriate technique for tendon grafting and to provide
reliable outcome studies the following criteria have been suggested by Boyes (1997) and
have been universally adopted (Hunter and Salisbury 1971, 1997, Paneva 1987,
Sakellarides 1987, Hunter et al 1997).
1. Good: This represents the ideal group, with minimal scarring of the skin and soft
tissue, good supple joints, no ligamentous or capsular contractures, and no major trophic
changes due to nerve damage. The loss of function of one digital nerve is not considered
detrimental.
2. Cicatrix: This group includes cases in which there was scarring after injury or
because of incorrect incisions, or in which a deep cicatrix followed infection after
attempted primary repair. The contractures usually result from deep scar tissue rather
than from joint stiffness. In a few instances a preliminary Z plasty is performed or a

pedicle flap is applied to repair the soft tissue damage before tendon reconstruction is
carried out.
3. Joint damage: Cases are classed in this group when the range of passive motion of
an interphalangeal (IP) joint is restricted. Rehabilitation is mandatory and free passive
motion, as far as possible, must be obtained before the tendon is reconstructed.
4. Nerve damage: This represents a small group, limited to those cases in which
damage to the major nerve trunk caused trophic changes in the fingers and results in
shiny skin and secondary stiffness of the joints. In some instances the major nerve
damage is repaired, and the tendon is reconstructed after nerve regeneration has taken
place.
5. Multiple damage: When tendon damage is not confined to one digit, an attempt is
made to reconstruct all the damaged tendons in one operation. Many of these cases are
complicated by other factors, such as cicatrix and joint stiffness.
Selection of the reconstructive procedure

Several options are available to repair a severe tendon defect. The following criteria and
considerations are applicable both to extensor and to flexor tendons.
Intercalated tendon graft

Intercalated tendon graft between the distal stump and the corresponding muscle can be
accomplished provided that free gliding is present in the entire unit and no irreversible
changes, such as myostatic contracture are present. This is more likely in proximal
lesions (zone V of flexor tendons; Fig. 1) and zones VI and VII of extensor tendons (Fig.
2), where retain
Figure 2
ing structures such as vincula, junctura tendinum, intertendinous connections are absent.
Static and dynamic sonography are usually helpful to locate the proximal stump and
assess the corresponding excursion.
Selection of a neighbouring motor

This routinely applies to flexor tendon reconstruction in ‘no-man’s land’, when both the
superficialis and profundus tendons have been injured. Only one tendon will be
reconstructed and the proximal connection is usually made at the palm and wrist to the
corresponding profundus.
Figure 3
The end to side suture

This is a sort of compromise but can provide excellent outcomes. It implies that the distal
tendon is sutured to an intact neighbouring one. This technique is often selected for
multiple pathological ruptures linked to inflammatory diseases, such as rheumatoid
arthritis, but is also indicated in older patients who may not tolerate staged reconstructive
procedures. The suture can be successfully placed for the flexor tendon both in the palm
and the wrist. For the extensor tendon this procedure is more frequently carried out on the
dorsum of the hand (Fig. 3).
Tendon transfer
When the injury has occurred in the palm or wrist, transfer of an adjacent FDS might be
considered as an alternative to grafting as this involves only a single tendon suture
(Bishop et al 1996). In large tendon defects mainly on the dorsum of the hand, the tendon
transfer—usually extensor indicis proprius (EIP) and extensor digiti minimi (EDM)—
might not reach the recipient tendon and should be extended with a tendon graft (see
Case 1 Figs. 1-8, 1-9 later in this chapter).
Tendon prosthesis
Hunter has pioneered the idea of an active tendon prosthesis fixed distally by bone
ingrowth and proximally to a musculotendinous unit with the aim of providing active
motion of the corresponding digit within a reasonable span of time. The implant is
constructed of silicone rubber with a Dacron core ending proximally in a loop and
distally in a small plate. This will potentially remain as a permanent prosthesis (Bishop et
al 1996, Hunter and Salisbury 1997, Hunter et al 1997).
Tendon allograft or xenograft

No consolidated clinical experiences support the routine application of tendon allograft
and xenograft (Bishop et al 1996, Tubiana 1997).
Selection of the graft

Many factors affect selection of the graft: locally available material (Boyes 1997),
required tendon length, calibre, facilities for harvesting, anaesthesiological implications,
anatomical variations (Bishop et al 1996), possibility and adequate skills for harvesting
vascularized grafts and use of a synovial versus extrasynovial tendon (Seiler and
Gelberman 1997).
Biological considerations
• The following conclusions have been drawn from experimental data emerging from
research conducted in the rabbit intrasynovial flexor tendon:
• Blood flow in flexor tendons is related to metabolic activity and young animals
possess a higher lactate dehydrogenase (LDH) activity as compared to tenocytes from
the adult animal.
• The tendon transplanted in the knee joint possesses intrinsic capacities for healing
(Lundborg 1976).
• The repaired tendon might survive in the knee joint as a floating structure, but to
function properly blood supply is crucial except for some anatomical areas of the
tendon, such as on the volar aspect where the synovial nutritional pattern might
prevail (Landi et al 1980a, 1997a).
• In the canine model extrasynovial (peroneus longus) and intrasynovial (flexor
digitorum profundus (FDP)) tendon grafts to replace injured flexor tendons were
compared (Seiler and Gelberman 1997). Intrasynovial grafts were completely
incorporated with preservation of the gliding surface. In contrast, tenocyte necrosis
and obliteration of the gliding surface from peripherally ingrown adhesions were
observed in the extrasynovial graft. DNA content and intravital staining using
calcium-AM and ethidium-bromide clearly showed survival of the original tenocytes
only in the intrasynovial specimen.
• Light microscopy and ultrastructural morphology of the normal chicken and human
flexor tendon sheath unit (Salamon 1997) confirmed the presence of two types of
synovial cells: type A presenting at a different level of the synovium with phagocytic
activity; and type B with the features of secretory cells. The same findings have been
confirmed in specimens taken from the pseudo-sheath 6 weeks after replacing silicone
implants by autologous tendon grafts.
Thus, the cumulative evidence suggests that the intrasynovial flexor tendons are best
replaced by intrasynovial tendon grafts (Gelberman et al 1992, Seiler and Gelberman
1997).
Sources of tendon grafts

Palmaris longus: Easily harvested from the ipsilateral forearm, this represents the most
frequent choice for palm to finger grafts. Its presence (85% of individuals) should be
verified preoperatively by asking the patient to simultaneously flex the wrist and oppose
the thumb to the small finger. Harvesting can be achieved through a short incision at the
wrist areas using a Brand tendon stripper (Bishop et al 1996) (Fig. 4). Care should be
taken to maintain the appropriate
Figure 4
tension and ascertain the correct direction so as to avoid premature detachment.

Plantaris longus: Present in more or less the same percentage of individuals as the
palmaris longus. Unlike the palmaris, it cannot be clinically assessed preoperatively but
can be identified by ultrasonography (Wilson 1985). The plantaris, which can reach a
length of 18 cm, is harvested through an incision made on the medial border of the
Achilles tendon (Tubiana 1965). The same precautions as for the palmaris longus should
be taken when using a long Brand tendon stripper. According to Hunter, it can be
harvested under local anaesthesia and sedation (Hunter and Salisbury 1997, Hunter et al
1997).
Extensor digitorum longus of the toes: The long extensors of the central toes are
routinely used when the palmaris longus and plantaris longus tendons are absent. They
are usually harvested through multiple transverse incisions made distal to the level of the
MP joint, and proximal to the conjunction with the corresponding extensor digitorum
brevis (EDB) tendon (see Case 2 Figs 2-7, 2-8 later in this chapter). This is usually
lacking for the fifth toe. Therefore, when needed, up to four grafts can be taken. The use
of a tendon stripper might be dangerous at this level because of the numerous
intertendinous connections. It is preferable to approach the graft by adding a transverse
incision on the foot and a longitudinal incision proximal to the extensor retinaculum
where each single tendon can be separated after dissection has been facilitated by
passively flexing and extending the ankle.
Flexor digitorum superficialis: This has been utilized as a pedicled graft by Paneva-
Holevich since 1965 (Paneva 1987). Its application as an intercalary profundus graft was
routinely considered by Boyes (1997) and Tubiana (1997). The related work by
Gelberman and Seiler (Gelberman et al 1992, Seiler and Gelberman 1997), in addition to
improvement of tendon juncture techniques will probably create new interest for the use
of this intrasynovial tendon, especially through the vascularized and pedicled version.
Extensor proprius tendons: We do not usually consider these when selecting grafts
but it should not be discounted because at least a good portion of the graft is intrasynovial
(Bishop et al 1996).
Flexor tendon grafting in zone II (Fig. 1)
The standard technique of flexor tendon grafting

Surgical exposure depends on previous scars and surgical approach. Whenever possible,
a lateral incision is selected at a site less relevant for tactile function (Fig. 5, Tubiana
1965, Bishop et al 1996). When a Bruner incision was used in previous surgery this can
be followed (Fig. 6a). When grafting procedures are undertaken in a replanted finger we
use a mini-Bruner incision on the opposite site whenever a single artery repair was
carried out (Fig. 6b). In the failed primary flexor tendon repair in zone II a curvilin-
Figure 5
Figure 6a
ear approach is made on the palm in such a way that the proximal suture of the graft does
not coincide with the line of incision. At the wrist a curvilinear incision is made on the
radial aspect for the grafting procedure of the flexor pollicis longus (FPL) and on the
ulnar site for the FDP of the long fingers (Fig. 5).
The incision through the subcutaneous tissue should be made exactly in the middle of
the finger to avoid the repaired nerves and vessels with particular caution if arterial
repositioning was carried out during the previous procedure (Landi et al 1997a).
Tendon sheath isolation: From the centre the sheath can be easily isolated. Its
damaged portion should be removed and release of flexors should then be started distally
and proximally to converge in the damaged area. It is crucial to assess the condition of
the superficialis. This might be intact, adherent, partially damaged or interrupted. In the
presence of continuity accurate tenolysis should then be undertaken. Wherever possible,
the sublimis might also be considered per se as a source for pulley reconstruction and
tendon grafting (Paneva 1987, Bishop et al 1996, Boyes 1997, Tubiana 1997).
Preservation of the number, location and width of the remaining annular pulleys is
mandatory.
Figure 6b
Assessment of the proximal stump is made through the palmar incision.

The lumbrical muscles should be separated and the corresponding myotendinous unit
mobilized. A passive excursion (average 3 cm) is sufficient to consider the proximal
stump adequate for immediate or future attachment of the graft. When local conditions,
due to inadequate skin padding, scarred bed, stiff proximal stump etc., are considered
unfavourable, a staged procedure should be taken into consideration and the site of the
proximal suture moved to the distal forearm.
Distal fixation: In 1992, we mailed a detailed questionnaire regarding surgeons’
criteria for treating acute tendon lesions. The majority of surgeons considered the
difficulty of repair of the extensor tendons of the fingers in ‘no-man’s land’ to be equal to
that of the flexor tendons (Landi et al 1997a).
A similar majority of surgeons from all continents indicated that the Bunnell pull-out
suture, using wire as suture material, was the technique of choice for distal flexor tendon
attachment. In adults this suture is performed first after the graft has been passed through
the pulleys and the remnants of the sheath. The distal part of the profundus might be split
into two parts. A small
Figure 7
cortical window is made just distal to its insertion. An oblique tunnel is prepared in the
direction of the proximal third of the nail complex. Dorsal cortical penetration by the drill
should be avoided. A 3-0 crisscrossed Bunnell monofilament type of suture is placed in
the distal graft using a double long straight needle which will be passed through the
tunnel to allow a suture to be placed through the nail bed distal to the lunula. When a
monofilament is used the pull-out is not mandatory as when wire is selected as suture
material (Boyes 1997). Additional 5-0 absorbable sutures are added to improve the
tendon to bone and periosteum contact. Alternatively, distal attachment can be achieved
without interfering with the nail bed with a bone anchoring device which still allows an
end to end suture between the residual flexor tendon stump and the distal part of the
tendon graft (Fig. 7).
In children, one should bear in mind that, whilst the extensor tendon attaches to the
epiphysis in both PIP and DIP joints, the flexor tendon attaches to the metaphysis and this
is the anatomical area where the distal repair should be placed. The technique differs
from the one adopted in adults in three basic ways: the bone tunnel is to be avoided, bone
anchoring devices are contraindicated and any external device such as a felt pad and
button should not be used.
The graft is secured to the distal stump by a Bunnell type of suture using 5-0 synthetic
braided material (Osterman and Paksima 1997). Side reinforcement is obtained by 6-0 or
7-0 extra sutures (Fig. 8). The graft is then passed along the palmar surface. The tendon
will be cut flush with the skin and secured to it by rapid, absorbable 4-0 or 5-0 nylon
suture. The pulp fixation method is now completed. The distal suture is performed first
even in children.
Proximal fixation: This type of repair is strictly related to the size of the donor graft.
No differences in technique are required in children as compared to adults apart from the
size of the suture material. A grasping suture is recommended for direct end to end repair.
This is usually the case when the sublimis is selected both as a free (Boyes 1997) or
pedicled tendon graft (Paneva 1987).
The Pulvertaft weave technique is the most frequently utilized proximal repair (Paneva
1987,
Figure 8
Figure 9
Schneider and Hunter 1993, Bishop et al 1996, Boyes 1997, Hunter and Salisbury 1997).
It is the best method when a discrepancy exists in terms of size between the graft and
recipient tendon. Palmaris longus, plantaris and toe extensors are the mostly commonly
used tendon grafts. The stump is fish mouthed and the graft is usually double passed
using a sharp tendon retriever. Proximal suture is secured by a synthetic braided suture
(Fig. 9). There is unanimous consensus that tension, both in adults and in children, should
be adjusted so that each finger is slightly more flexed than its radial neighbour (Paneva
1987, Bishop et al 1996, Boyes 1997, Osterman and Paksima 1997, Tubiana 1997).
Preservation and reconstruction of the pulley system: The pulley system plays an
important role in controlling the overall tendon excursion in the ideal, uninjured setting.
The pulley system serves to prevent bow-stringing of the tendon across the volar aspect
of the joint in flexion. The residual or reconstructed pulleys should not only be located
appropriately, but should also be of the proper diameter to resist attenuation or
breakdown (Schneider and Hunter 1993).
At least two pulleys, A2 and A4, need to be retained or reconstructed (Bishop et al
1996, Nishida et al 1999) (see Case 3 Fig. 3-5 later in this chapter). In agreement with
Schneider (1997a,b) we believe that, when possible, a three
Figure 10
or four pulley system should be aimed for (Fig. 10). As a general rule, since the
reconstructed pulleys might interfere with volar plate or collateral ligament function,
these should not be placed in correspondence with the MP and PIP joints. Ideally, one
pulley should be placed proximally and distally to each joint requiring reconstruction (see
Case 2 Fig. 2-3 later in this chapter).
Weak pulleys should always be reinforced by a crisscrossed suture secured to the
fibrous rim of the sheath. Pulley disruption might be encountered, especially during a
single stage grafting procedure, since considerable forces act across pulleys. A 3 N
(newtons) force at the fingertip may in fact create a 107 N force on a pulley (Hume et al
1991).
Besides the number and location of the pulleys other factors are also important when
considering pulley reconstruction, such as the tension and intrinsic structure of the
grafting material and related biomechanics (Bishop et al 1996, Nishida et al 1999). The
recommended proximal to distal width of a reconstructed pulley is
Figure 11a
approximately 5 mm (Doyle and Blythe 1975). Wider pulleys add strength that will allow
earlier postoperative motion. Lin et al (1989) evaluated three methods of pulley
reconstruction. The fibrous rim described by Weilby (1968), the palmar plate belt-loop
described by Karev (1984), and the triple loop method described by Okutsu et al (1987)
(Fig. 11a). Only the triple loop could withstand as much load (520 N) before failure as a
normal pulley.
The pulleys should also have adequate tension as they tend to loosen over time
(Bishop et al 1996) without interfering with tendon gliding. As the flexor tendon–tendon
sheath interaction is influenced by the nature of the graft (intrasynovial tendons
producing, at least in vitro, less excursion resistance than extrasynovial tendons (Nishida
et al 1999), the pulley reconstruction is deeply influenced by the nature of the grafting
material. In vitro intrasynovial tissue sources (extensor retinaculum, volar plate and
flexor superficialis tendon) have produced less excursion resistance than extrasynovial
tissue sources (extensor digitorum and palmaris longus) (Nishida et al 1999).
Figure 11b
All the above factors should be considered before selecting the method of pulley
reconstruction.
Methods of pulley reconstruction

Pulleys based on remnants: This is usually the first option when there is generally
sufficient tendon material available to construct pulleys by free tendon grafts. These can
be sutured to the rim or the periosteum. This type of pulley employs a suture on both
sides—therefore, the folding residual anatomical structure should be equally reliable (Fig.
11b)(see Case 4 Fig. 4-1 later in this chapter).
FDS tail: If FDS insertion remains intact (and this is often the case), this remnant can
be utilized to reconstruct part of the A4 or A3 pulley. The tail must be securely fixed, and
we prefer the criss
Figure 12a
cross type of suture using braided non-absorbable material anchored to the bone in a safe
area, distally (for A4 reconstruction) (Fig. 11b) or proximally to the PIP joint (for A3
reconstruction).
The single or multiple loop technique: The loop technique may be single, one and a
half, double or triple. The graft encircles the phalanx and is secured to the sheath
remnants or to bone by a bone anchor. An adequate length of tendon graft must be
harvested since approximately 6–8 cm of tendon is required for reconstruction of one
loop (Schneider and Hunter 1993). The loop will be placed underneath the extensor
tendon and extensor retinacular system, both at the distal metaphysis of the metacarpal
and at the proximal phalanx (Fig. 11a). The double or triple loop should be placed around
the tendon or rod and secured with 3-0 multiple non-absorbable suture.
To reconstruct the A4 pulley the graft is placed dorsal to the extensor mechanism at
the base of
Figure 12b
the middle phalanx (Fig. 12). Under ideal circumstances a three-pulley system can be
entirely rebuilt using palmaris longus as a graft in the following way: A2 using the
double or triple loop technique; A3 using the FDS tail technique; and A4 using the single
loop technique at the base of the middle phalanx.
The extensor retinaculum: Lister (1979) popularized the use of the extensor
retinaculum in place of the traditional tendon graft. It has a width of 10 mm, which is
adequate for a pulley, and leaves sufficient retinaculum to avoid bow-stringing of the
extensor tendons. The smooth undersurface of the retinaculum provides the best gliding
surface for the flexor graft (Nishida 1999). It can either pass around a phalanx as one
loop or be fixed to the rim remnant or to the bone by bone anchors.
The drawbacks are the limited length and poor cosmesis of the donor area. The belt-
loop method uses the volar plate (Karev et al 1987) to reconstruct the A3 pulley.
Whenever available, we prefer the FDS tail for this purpose. Furthermore, the most
critical A2 and A4 pulleys are not reconstructed and adjunctive procedures are therefore
needed.
We introduced the ‘running pulley’ in cases of complex tenolysis with unsightly and
disturbing bow-stringing in the palm following multiple flexor procedures. A2 and A4
pulleys are reconstructed following the same rules of the loop technique but in a
continuous fashion. The two tails of the graft are secured to the phalanx or metacarpal
bone by bone anchors (Fig. 12a, b). This technique allows early motion (Landi et al
1997a, 2002) and leads to good functional results. It is now being used during the first
phase of the flexor tendon grafting technique when the pulley system is extensively
damaged.
The wide availability of biological materials obviates the need for artificial materials
to reconstruct the flexor retinacular system (Schneider 1997b).
Techniques for flexor tendon grafting
The single stage tendon grafting technique

This is best indicated when the pulley system is preserved and the flexor sheath is
minimally scarred. These criteria are usually met by the good group of Boyes’
classification (Boyes 1997, see above). In the clinical setting, single stage grafting is
indicated in cases of unrepaired flexor tendons in ‘no-man’s land’, in cases of secondary
rupture of partially lacerated flexor tendons, and in well-selected cases of delayed
treatment for flexor profundus avulsion (see Case 5 Figs 5-1–5-3 later in this chapter).
The surgical techniques for the distal and proximal repairs follow the guidelines
described above.
Rehabilitation: Rehabilitation is routinely started 10 days after surgery, when the skin
has started to heal, minimizing the risks of skin dehiscence and infection. An extensive
block splint is used for 4 weeks placing the hand in a safe position. A resting static splint
both to prevent MP joint contracture and rupture of the graft at the attachment sites is
worn while sleeping. During day time the scheduled exercise programme will follow both
the Kleinert and Duran principles. The daily dynamic splint is removed at 4 weeks and
rubber bands are connected to an armlet placed over the flexion crease for an additional 2
weeks. The resting splint is still worn at night. From the eighth week place-holding and
active exercises start in sequence. Strengthening is allowed after 12 weeks.
Early complications: Early breakdown at the proximal or distal attachments of the
graft have been reported (Paneva 1987, Bishop et al 1996, Schneider 1997a). When
rupture of a graft attachment is recognized promptly the procedure can often be salvaged
by early reoperation. Ultrasound evaluation will facilitate locating the site of rupture.
This complication occurs more commonly at the distal attachment, and, if the tendon
cannot be advanced to the original site of attachment, to avoid the flexion deformity of
DIP joint that inevitably follows, the end of the graft can be inserted into the middle
phalanx creating the ‘superficialis finger’.
A proximal attachment disruption is usually represented by slippage of the graft
interweave in the distal forearm. Reattachment and salvage are often possible.
Pulley breakdown is another issue and is diagnosed on reduction of the acquired range
of motion with bow-stringing of the tendon graft. Blocking support by external pulleys
might be helpful (Schneider 1997a)
Late complications: Adhesions of the tendon graft will interfere with the potential
overall excursion. Clinically the tenodesis site can be located only by flexing in sequence
the wrist and the other joints (Landi et al 1997a,b) or by dynamic ultrasound. Tenolysis
of the graft should then be considered and undertaken 6 months after the primary grafting
procedure. It is advisable, when dealing with tendon grafting procedures, to describe
them as staged procedures, and it should be clearly mentioned in the consent form
presented to the patient that subsequent interventions might be required to achieve the
best possible outcome.
The staged tendon grafting techniques

The flexor tendon sequelae of the ‘cicatrix’ and joint and nerve damage groups of the
Boyes’ classification are amenable to treatment using the staged techniques of tendon
grafting. As a prerequisite, any soft tissue problem, nerve and joint contracture should be
addressed before embarking on such a demanding procedure, which is usually carried out
in two stages.
Two types of staged technique are followed at present: the Hunter (Hunter and
Salisbury 1997) and the Paneva-Holevich (Paneva 1987) techniques.
According to Boyes’ classification, for both options the patients should have
undergone a complete rehabilitation programme and the best possible local condition
should have been obtained. Joint and soft tissue contractures should be dealt with before
carrying out the first stage of the procedure. Relevant sensory deficits and painful
neuromas are the only conditions which might be treated during the first phase, as nerve
grafting is compatible with the rehabilitation procedures required during stage one.
Stage one: This is performed following the surgical step already described. It is
important at this stage to leave a stump (0.5 cm) of the flexor tendon attached to the distal
phalanx and to excise the scarred lumbrical to prevent the paradoxical motion
occasionally seen after tendon grafting, which causes the finger to extend rather than flex
as the patient attempts to flex the finger completely (the lumbrical plus sign is described
by Parkes 1971).
During this phase the tendon silicone implant is inserted after it has been passed
through the retinacular system to re-establish a new functional tendon sheath. A
precaution needs to be observed at this time: because silicone rubber is highly
electrostatic and attacks airborne particles it should be kept immersed in saline on
removal from the package and handled with atraumatic instruments. A ‘no touch’ policy
must be adopted and, in any case, gloves should be washed intraoperatively with aseptic
solution. Since the staged technique can seldom be performed in cooperative children to
overcome growth retardation caused by non-use of a digit, a variety of rods ranging from
2 mm to 6 mm is available. The implant is passed through the residual sheath in a
proximal to distal direction. The distal end of the prosthesis is sutured beneath the stump
of the profundus (see Case 2 Fig. 2-3 later in this chapter). A figure-of-eight suture of
monofilament on atraumatic taper-cut needle is used.
Careful assessment at the palm or distal forearm has to be made so that the implants
glide freely without binding or buckling (Hunter and Salisbury 1997) by passively flexing
and extending the fingers (see Case 2 Fig. 2-4 later in this chapter). The short rod is
selected for an unscarred palm, otherwise a long rod should be inserted through the carpal
canal to glide freely in the proximal area.
Following skin closure a standard postoperative dressing is applied with the MP joint
(40°) and PIP joint (20°) in moderate flexion. When a long rod is selected the wrist
should be also be immobilized in a neutral position for 10 days to allow skin healing.
The same precautions should be undertaken for implant surgery as for prosthetic
surgery. Prevention of infection should be made by a minimum 48 hour preoperative
administration of a first generation cephalosporin.
Rehabilitation following stage one: Passive flexion exercises start as soon as
complete wound healing has been achieved (about 10 days). Until then, immobilization
and splinting in the safe position are indicated.
Flexion exercises are carried out on a regular basis and buddy-taping will allow
exercise of the digit under control of the adjacent finger. The rehabilitation target during
stage one is to gradually restore full passive range of motion which is the prerequisite for
stage two.
Premature and overzealous rehabilitation might provoke aspecific synovitis and
infections.
Complications in stage one: Aspecific synovitis is a commonly recorded
complication in about 15–20% of cases (Paneva 1987, Bishop et al 1996, Hunter and
Schneider 1997). It is characterized by pain in the finger tip, swelling along the volar
surface of the finger, and swelling and erythema at the incision sites. This serious
complication is not necessarily followed by less unfavourable results. It is more frequent
in children, and this supports the argument to reserve the staged procedure for older
patients. Cultures for bacteria in the fluid found within these sheaths have consistently
shown no growth. The following precautions should be taken during the surgical phase:
observation of the ‘no touch’ technique, and multiple and careful cleansing of the
surgeon’s gloves. When synovitis is observed the patient’s exercise programme must be
interrupted for 1 week. In order to prevent bacterial contamination antibiotics are also
prescribed again as a prophylactic measure.
Dynamic ultrasound might reveal an underlying mechanical cause, such as buckling of
the prosthesis which might, in fact, underlie the fascial block. In the vast majority this
complication subsides. When synovitis does not respond to the proposed therapeutic
regime (although we do not know whether the new sheath will be structurally or
functionally modified as a consequence of this complication), a stage two procedure
might be performed earlier or when synovitis subsides and removal and deferral of stage
one to a latter time considered (Hunter and Schneider 1997). Real infection has occurred
in 2–3% to 15% in three series (Wehbe et al 1986, Amadio et al 1988). In this case
implant removal and appropriate antibiotic therapy are required (see Case 4 Fig. 4-3 later
in this chapter).
Stage two: The interval between stages one and two should be 2–6 months. Incisions
are very limited and the aim is to expose fully the proximal and distal attachment sites.
Leaving the distal end of the prosthesis attached to the distal phalanx, the rod with the
attached selected tendon graft is pulled distally through the new tendon sheath. The
sequence of sutures is placed according to the guidelines described above in a distal to
proximal direction, to set the appropriate tension of the graft.
Rehabilitation guidelines and complication rates following stage two do not
substantially differ from those already described for the single stage grafting technique.
Pedicled staged tendon grafting technique: This operation has been described by
PanevaHolevich in 1965 (Paneva 1987). The procedure involves the use of the flexor
superficialis of the same finger as a pedicled graft after it has been sutured in an earlier
stage to the flexor profundus usually at the level of the lumbrical muscle (See case 4 Fig.
4-2 later in this chapter). In the presence of a coexisting scar in the palm the preliminary
suture is carried out at the wrist level. The same area is selected for secondary
reconstruction of the flexor pollicis longus (FPL). In this case, the preliminary suture is
placed between the corresponding muscular tendon unit and the palmaris longus. No
earlier than 1 month after the first stage, the superficialis tendon is exposed and cut at the
level of musculotendinous junction. The tendon loop is then passed beneath the pulley
system and sutured to the distal phalanx. The method of suturing does not differ from that
suggested for the free tendon graft technique. The technique differs significantly from the
Hunter staged technique during the rehabilitation process. After stage two, the wrist and
fingers are immobilized in moderate flexion for only 5 days. Soon after the splint is
removed and the patient is encouraged to perform active exercises on a daily basis. A
splint is worn between the exercises and overnight for 25 days. From this point on the
rehabilitation schedule does not differ from that followed for the single stage grafting
technique. For the most unfavourable cases this procedure might be employed alongwith
the Hunter twostage technique (Tubiana 1997; see Case 4 later in this chapter).
The loop technique has several advantages. Grafting of the flexor superficialis, an
intrasynovial tendon, has the related biological advantages (Nishida et al 1998, 1999).
Furthermore, one repair has already healed when the second is undertaken. Chaplin
(1973) has also experimentally proved the presence of a microcirculation in the pedicled
tendon graft. The size of the superficialis tendon is wider than the usual extrasynovial
tendon graft. A better tendon graft–pulleys relationship is then re-established when the
original retinacular system is preserved. The superficialis tendon will then glide within an
appropriate and competent pulley system.
When the Paneva-Holevich technique is followed with preliminary insertion of a
tendon rod, the ideal setting of a unique tendinous distal suture is acheived.
Early rehabilitation can be undertaken with positive effect on outcome (Bishop et al
1996). In the presence of a severely damaged flexor tendon sheath necessitating extensive
pulley reconstruction, the Hunter technique might be preferable.
Complications after stage two: These are the same as those encountered during the
single stage grafting technique, apart from breakdown, which for the Paneva-Holevich
technique is confined to the distal repair.
Results of flexor tendon grafting: These are favourable in the ‘good’ group of
Boyes’ classification in 95.48% of cases. In the ‘cicatrix’ group only 40% of the patients
(reported by Boyes) achieved flexion to within 2 cm of the distal crease of the palm.
When comparing the single to the staged technique for the ‘scarred’, ‘joint stiffness’ and
‘multiple lesions’ groups, Hunter and Salisbury (1997) reported a significant
improvement when the latter was carried out. The results obtained in ‘unfavourable’
cases were also graded by Paneva-Holevich (Paneva 1987). Overall ‘very good’ and
‘good’ results were obtained in 63.73% of the series, and the outcomes were significantly
better when the Hunter modification was added to the original technique.
Other tendon grafting procedures

The ‘flexor superficialis finger’: The concept of a superficialis finger was initially
introduced and described by Osborne (1960, 1975) from Liverpool, England, as the
‘redemption operation’. A different name, for this technique ‘the proximal
interphalangeal joint motored finger’ was proposed by Schneider (1997a) but it

undoubtedly sounds less biblical. This procedure is based on the premise that 85% of the
arc of motion is achieved by full MP joint and PIP joint flexion. The technique is
indicated for the following circumstances:
• When flexor injury is associated with DIP joint damage or with distal disruption of the
extensor tendon insertion or with unreliable skin at this level (see Case 6 later in this
chapter).
• In case of rupture of the distal attachment of a tendon graft when the graft cannot be
reattached under acceptable tension to the distal phalanx.
• In the case of A2 or A4 pulley failure with bow-stringing of the tendon graft; in this
case simultaneous A2 reconstruction might be accomplished by the triple loop
technique.
• When the digit is graded 4–5 on Boyes’ scale.
This procedure can be undertaken as a salvage procedure or planned as a staged
procedure wherever active flexion of DIP joint cannot be re-
Figure 13
established (Fig. 13). The Hunter active tendon has also been used to implement the
flexor superficialis finger. This procedure is best for elderly patients or those in whom the
local tissue conditions would make a traditional tendon graft unlikely to function.
Isolated flexor digitorum profundus injury: In this situation treatment by tendon
grafting should carefully be considered on an individual basis when strict criteria are met
(Schneider 1997a,b). This technique is usually performed in young patients with supple
joints and with minimal scarring especially at the DIP joint level. Occupational needs
have to be ascertained after the digit acts as a ‘superficialis finger’ for certain period of
time but the performance is not felt to be adequate by the patient (see Case 5 later in the
chapter).
We agree entirely with Schneider (1997a,b) that this grafting procedure is better
indicated for the ring and little finger where power grasp demands are greater and
stronger flexion is required as compared to the index and long fingers, where loss of FDP
function will be missed less in daily activities.
Surgical technique: The FDS might be fully functional from the beginning. In this
case a single stage grafting technique is carried out possibly through or around the
superficialis decussation. In the presence of adhesions of the FDS, tenolysis is carried out
to restore the possibility of PIP joint active flexion. In this case a staged tendon grafting
procedure is preferred. The postoperative phase starts after 1 week when wound healing
is acceptable. Active exercises are carried out at the PIP joint and passive exercises at the
DIP joint, on a daily basis.
In summary, a single stage technique for isolated FDP reconstruction is rarely
indicated; Schneider used it on 25 occasions in nearly 30 years. We used it, always as a
staged technique, in six patients over the same period of time. In two cases aspecific
synovitis had to be dealt with, but in all cases the final outcome was good. A secondary
tenolysis was performed in 14 out of 25 tendon grafts in the Schneider series, and this
procedure finally re-established an excellent function at the DIP joint.
Late sequelae of flexor tendon grafting: The sequelae can be classified in
relationship to the underlying condition of the joints. In presence of a functional range of
passive motion tenolysis of the graft might be carried out. However, when dealing with a
fixed posture different salvage procedures should be considered (Landi et al 1997a,b)
Tenolysis after staged reconstruction has been performed in 16–45% of patients
following staged reconstruction (Amadio et al 1988, LaSalle and Strickland 1983).
Overall, 54% had good or excellent results—although only 19% had final TAM (total
active motion) greater than 180°. Factors associated with poor results included patients
younger than 10 years of age (Osterman and Paksima 1997) and those with ‘multiple
damage’ according to Boyes’ classification. In these cases finger adhesion can extend the
full length of the grafts especially in the presence of poor circulation. In the replanted
finger low oxygen tension would inevitably provoke adhesion formations to enable
survival of the graft (Hunter and Salisbury 1997, Landi et al 1985, 1997a). In this group
staged flexor grafting should therefore be considered from the start.
Fixed deformity: Skin and flexion contracture often coexist at the DIP and PIP joints
level following multiple interventions to the flexor tendons. The options for treating the
hook deformity range from a supplemental tenolysis of the flexor and release of the volar
plate to arthrodesis in a more extended position of one of the two IP joints or to digit
amputation.
Saffar, in 1978, introduced the total anterior teno-arthrolysis (TATA) (Landi et al

1997a). The surgical technique includes the following surgical procedures: access
through the lateral surface from the middle of the proximal phalanx to the distal phalanx,
incision of the subcutaneous tissue to the bone and dissection of the periosteum with a
straight rougine or scalpel from the diaphysis of the first two phalanges. Then the volar
fibres of the collateral ligament are incised, removing the volar plate that becomes
continuous with the previously detached periosteum (see Case 7 Fig. 7-1 later in the
chapter).
This surgical procedure is performed both at the PIP and DIP joints so that all
elements of the volar surfaces of the two phalanges are detached from the bone.
Sectioning of the collateral ligaments proceeds from volar to dorsal side, sparing the most
dorsal fibres. At times, part of the collateral ligaments of the DIP joint must also be
sectioned. If an attempt is made to extend the finger and extension is possible at the
expense of flexion of the DIP joint, the FDP must be sectioned closed to the periosteal
insertion, leaving the tendon attached to the surrounding tissue. The degree of gliding is
proportional to the severity of the hook deformity. It is not always necessary to obtain a
complete extension of the digit. If a small area of skin remains uncovered, it can be left to
heal by secondary intention or covered with a local flap (Landi et al 1997a, 2002).
Flexor tendon graft in zone III (Fig. 1)

In zone III the common digital nerve needs to be sutured. Ideally, both the superficialis
and profundus flexors should be also repaired. Practically only the FDP is reconstructed
and the FDS is used as a graft source. The scarred lumbrical muscles should be removed.
We prefer to use the minigraft technique instead of long grafts that reach the tips of the
fingers (see Case 8 Fig 8-2 later in the chapter).
When the minigraft technique is chosen this will require a localized fasciectomy since
the distal segment of the graft usually borders the A2 pulley and adhesions might occur.
The possibility of tenolysis has to be explained to the patients. Great attention should be
paid while doing this operation as the digital nerves or digital nerve grafts can adhere to
the skin.
Flexor tendon graft in zone IV (Fig. 1)

Zone IV represents an area of crowded anatomical structures which pass through the
carpal tunnel. Extensive tendon loss in this area carries a high risk of development of
extensive adhesions. Simultaneous damage to the median nerve requires secondary repair
by nerve grafting. The following guidelines should be observed:
• The superficialis tendon should be removed.
• The flexor tendons of long fingers and FPL should be repaired by tendon grafting. If
graft sources are insufficient an end to side suture can be considered between the deep
flexor of the little and ring fingers.
• The flexor retinaculum should be excised, and a secondary tendon transfer by the best
rerouting to the abductor pollicis brevis should be planned at this early stage.
The suture technique is based on personal preference. We prefer, at this level, the single
core loop technique suture with 3-0 braided nonabsorbable filament in adults, as
described by Tsuge (1998), reinforced by a separated epitendinous repair with 5-0
monofilament (see Figs 17a, b).
Flexor tendon graft in zone V (Fig. 1)

Tendon grafts are usually required following complex lesions especially due to trauma,
physical or chemical agents, where hand survival and soft tissue skin coverage are at the
top of the priority list. Following soft tissue repair, when needed, a secondary new repair
is done by traditional nerve grafting. Direct interpositional tendon grafting cannot be
undertaken due to both the extensive scarred bed and the proximal damage to the
myotendinous unit. Tendon transfers, usually BR (brachioradialis) to FPL and ECRL
(extensor carpi radialis longus) to FDP, represent the usual alternatives (Tsuge 1988; Fig.
14a,b). One-stage reconstruction of postelectrical burns for forearm and hand defects
might be accomplished by using microsurgical transfer of an ulnar
neuromyotenocutaneous unit, which has been suggested as a unique treatment in a
difficult setting. To prevent adhesions, or in association with secondary tenolysis, a
locally reabsorbable gel composed of gelatine and carbohydrate polymer buffered in
phosphate (Adcon-TN, Glyatech, Cleveland, USA) might be added (Landi et al 1997a,
2002) When tenolysis of the tendon grafts is required, both at the palm and wrist, great
attention should be paid so as not to damage nerves or nerve grafts.
Repair of the extensor tendon defects
Late reconstruction of the extensor tendons can be as difficult as for flexor tendons.
Functioning
Figure 14a
Figure 14b
of the extensor tendon assembly has been defined by Littler as a ‘fugue of movement’
(Burton and Melchior 1982)
The retinacular system, although structurally very thin, plays a relevant role in the
functional chain as the dynamic system of the extensor apparatus is harmoniously
interrelated. An imbalance at one joint will trigger a predictable deformity in the next
adjacent joint. Contracture of the oblique retinacular system will lead to the fixed
‘boutonniere deformity’ (Fig. 15). A fixed swan-neck deformity is maintained by contrac
Figure 15
ture of the triangular lamina. In addition, the extensor mechanism has far less tolerance
than the flexor system in relation to changes in tendon length (Burton and Mechior 1982)
Injuries proximal to the juncturae tendinum will lead to contracture of the motor unit.
This precludes the possibility for direct secondary repair in the vast majority of cases.
The following myostatic muscle contracture creates a gap between the disrupted tendon
stumps. Direct repair of an irreversibly contracted motor unit will prevent finger flexion
due to the extensor tenodesis effect. These are the basic principles underlying the more
frequent use of tendon transfers for late reconstruction of the extensor tendons. Joint
contractures are often associated and should be released before embarking on extensor
tendon grafting procedures at any level. The dorsal skin of the hand is thin and pliable to
allow flexion of the underlying joint. This skin is not easily replaceable, and certainly the
only possible replica can be provided by skin from the dorsum of the foot by means of a
dorsalis pedis composite flap (Landi et al 1980b, Caroli et al 1993). The thin elastic skin
of the dorsum of the hand, when damaged, lacks a priori the subcutaneous padding that
allows secondary tendon procedures to be carried out. The methods of repair and
technique of tendon grafting are strictly related to the level of injury (see Fig. 2).
Repair or secondary reconstruction of the extensor retinacular system is also a relevant
issue. Tendon reconstruction of the extensor hood deficit is mandatory at the MP joints
when dislocation of the tendons on the groove causes friction and pain. This is also
applicable in the presence of painful sequelae of release of the first dorsal compartment
(Rozmaryn and Rockville 1995, Ramesh and Britton 2000). Similar to a zone V injury of
the flexor tendons, where the flexor retinaculum is not repaired, in zone VII injury of the
extensor tendons the extensor retinaculum should not be reconstructed to prevent de certo
adhesions in this area. In any case, a natural tenodesis effect is provided by flexion of the
wrist.
Release of the contracted retinacular system has been introduced as adjuvant therapy
for the fixed deformity of the fingers sustained by the imbalance of extensor tendon
mechanism (Fowler 1959, Dolphin 1965) (Fig. 15).
Single stage tendon grafting can be considered for large defects on the dorsum of the
fingers and hand only when ideal conditions of the overlying soft tissues exist (Cautilli
and Schneider 1995). The braided plantaris tendon has been suggested as an extensor
tendon graft source for this (Baker 1995). The staged technique has been used in a
potentially scarred bed. It has been used after chronic burn wounds or infection treated by
free tissue transfer (Tomaino and Plakseychuck 2000). Limited experience has been
reported with the use of vascularized extensor tendon grafts. The extensor indicis
proprius (EIP) appears to be the only appropriate local source (Vermeylen and Monballiu
1991).
Tendon transfers are routinely used for chronic lesions of the EPL (extensor pollicis
longus), or EDC (extensor digitorum communis), whenever EIP or EDM are available.
Composite tissue transfers allow one-stage reconstruction of simultaneous skin and
extensor tendon loss by means of a regional vascularized flap, namely the radial forearm
flap, including vascularized tendons (Hiroshi et al 1996, Sukkar et al 2002). Under ideal
conditions composite free tissue transfer can also be considered from different sources
(Ichioka et al 1994). The upper lateral arm has been used by Hou (Hou and Liu 1993),
and the dorsum of the foot by Taylor (Taylor and Townsend 1979) and Landi (Landi et al
1995). The cost–benefit assessment of the procedure, especially for the latter, should take
into account donor site morbidity (these aspects are dealt with elsewhere in this book).
Consideration of donor site morbidity is often associated with cosmetic considerations,
which are based both on individual perceptions and on cultural background (Hirochi et al
1996). More precise guidelines in terms of repairs of defects of the extensor tendons can
be drawn in relationship to the affected anatomical area.
Zones III and IV (Fig. 2)

The most frequent lesions that afflict the extensor apparatus and frequently the skeletal
system occur in zones III and IV, usually in the work place but also during recreational
activities.
Skin resurfacing is the main issue. Reproduction of the dorsal interrelated system
might not be realistically achievable. Therefore, some general guidelines should be
followed. Preliminary soft tissue resurfacing is strictly related to involvement of a single
digit or multiple digits. When dealing with a single digit, some local flaps are for the
most part of historical interest but can occasionally be used, such as the flag flap (Iselin
1973) and the digital arterialized lateral finger flap (Russel et al 1981). Other flaps have
more recently been introduced, and we believe that the reverse adipofascial turnover flap,
for complicated dorsal skin defects both at the level of the digits and hand, is worth
considering (Lai et al 1991). It usually has a base to length ratio of 1:1.0–1:1.5.
Dissection of the flap has to be stopped in the finger about 1.0 cm before the edge of the
defect is reached. A full or split thickness graft is applied to the raw area of the turnover
flap.
When dealing with multiple digits, dorsal skin defect free flaps, such as the lateral arm
flap, should be considered whenever possible, keeping in mind that no regional flap will
be able to cover such an extensive area, apart from the radial forearm flap. Traditional
reconstructive techniques can be used, depending on the centre and surgeon’s experience,
with the provision that thin or defatted skin should ultimately be provided.
For the extensor apparatus, in a complex lesion DIP joint control is usually left to the
retinacular system and the central band is reconstructed by means of one of two widely
accepted techniques: the reverse central tendon pedicled graft as suggested by Snow
(1973) (Fig. 15) or the tendon graft suggested by Fowler (1959) (Fig. 16). We prefer the
former technique. Distal attachment is usually secured by a bone anchor. As for any
extensor grafting procedure, immobilization is maintained in the safe position for 3
weeks. A tailored rehabilitation programme will then be started, taking care to avoid
stretching of the sutured graft during the following weeks.
Zones V and VI (Fig. 2)

These zones are also frequently affected. The corresponding lesions at T III or T IV in the
thumb are less common. The overall surgical strategy depends on various factors. In the
emer
Figure 16
gency setting, the reconstructive procedures for skin damage or loss are strictly governed
by the anatomical area and corresponding extension. Limited loss to one ray in zone III
can be treated by a reverse dorsal hand flap (Quaba and Davison 1990)
Approximately one-third of the dorsum of the hand in zone IV and of the dorsum of
the thumb can be resurfaced by the posterior interosseous flap (Landi et al 1991). The
adipofascial turnover flap can also be considered (Lai et al 1991)
Secondary reconstruction of extensor tendon defects can be achieved with minigrafts
taken from the various sources available just as for flexor tendons reconstruction (Fig.
17). This procedure can be used for the thumb to reconstruct EPL at the T III level. At the
T IV level, proximal contracture of EPL usually occurs, and EIP is transferred to
reconstitute active extension of the thumb. We prefer the suture technique proposed by
Tsuge (1988). Regarding the technique for suturing the extensor tendons grafts, the core
suture is achieved by applying a looped braided non-absorbable suture (3-0 in adults)
reinforced by a supplementary epitendinous suture using 6-0 monofilament (Fig. 17).
When the entire dorsum of the hand has been severely damaged in a young motivated
patient, surgeons who are acquainted with the dorsum of the foot as a donor area for
reconstructive procedures can opt for the composite dorsalis pedis flap. Experience in this
field is still minimal and prevention of donor site morbidity relies on preservation of EDB
innervation and strict immobilization of the foot to guarantee taking of the graft (Landi et
al 1980b).
When confronted with skin defects in the order of 10 × 6 cm, the radial forearm flap,
which may include vascularized tendons (the duplicated palmaris longus, flexor carpi
radialis, and brachioradialis (Haroshi et al 1996; see Case 9 later in this chapter) has a
good indication in a situation where microvascular procedures are contraindicated. We
use it in older patients as an alternative to distant flaps. Caution should be taken to place
the suture of the graft at a distance from the skin suture. Dealing with an almost circular
flap, a trapdoor effect is foreseeable and secondary tenolysis should be anticipated
(Hiroshi et al 1996).
Among the complications that can occur exposition of the suture with secondary
infection and breakdown can be prevented by including part of the flexor carpi radialis
muscle in the flap (Sukkar et al 2002). As a third option, just skin coverage can be
accomplished in the emergency setting.
Secondary minigrafts to the extensor tendon can be performed by elevating half of the
flap and defatting as needed. Simultaneous tendon transfer can also be accomplished (see
Case 10 later in the chapter).
The staged extensor tendon reconstruction remains the last resort and should be done
through small proximal and subcutaneous tunnelling of the silicone rods. This technique
has been used even under split thickness skin grafts (Bevin and Hothem 1978)
Zone VII (Fig. 2)

The wrist extensors are also damaged in this zone. The ECRL tendon is usually used as a
free graft to reconnect the ECRB (extensor carpi radi-
Figure 17
alis brevis) to the corresponding metacarpal (see Case 1 Fig. 1-2 later in the chapter).
Tendon grafts to the long fingers are usually intercalated with the provision that EDC
myostatic contracture has not developed. In this case BR is usually transferred to the EPL
and FCU (flexor carpi ulnaris) to the EDC (Fig. 18). The extensor retinaculum is
discarded.
Zone VIII (Fig. 2)

For extensive skin losses in the acute phase the anterolateral thigh flap based on
perforators has recently gained renewed interest (Javaid and Cormack 2003). By
exploiting the chimeric flap principle it can also be used to revascularize the hand and
thanks to its dimension (20 × 10 cm) it might cover the entire dorsum of the hand and
distal forearm. For late extensor tendon reconstruction no other options besides tendon
transfers occasionally prolonged by tendon grafting can be considered (Burton and
Melchior 1982, Javaid and Cormack 2003).
The late sequelae of extensor tendon grafting: Similar to the flexor tendons, the
extensor tendon grafts can adhere to the floor in the neutral zones, especially at the
dorsum of the hand. In the presence of supple joints, a simple tenolysis is required after 6
months of the preliminary procedure. The four cases that we have treated were confined
to zone III–zone V. The range of motion gained ranged from 45° to 90° (Landi et al
2002).
Teno-arthrolysis of the dorsal apparatus (TADA) becomes necessary when adhesions
and joint
Figure 18
stiffness occur as sequelae of infection, inflammatory reactions, closed trauma, and

tenorraphy or tendon grafting of the extensors at the dorsum of the hand and fingers.
TADA can be accomplished via two modalities, depending on whether tenolysis is
required following tenorraphy and tendon grafting of the extensor apparatus or closed
trauma of the fingers and hand. In the former, tenolysis extends in both directions from
the site of anatomic fixation, and involves clearcut surgical steps, because at the PIP joint
the central band must be isolated from the lateral bands, and at the MP joint, the extensor
hood is almost inevitably sacrificed. The sagittal bands are usually the only retinacular
structures that are preserved. However, extrinsic stiffness is often associated with an
intrinsic stiffness of the MP and PIP joints. In this case, one proceeds with a dorsal
capsulotomy at the MP or PIP joint. The traditional hesitation as regards secondary
tenolysis of the extensor tendon graft should be reevaluated in the light of contemporary
techniques of hand rehabilitation (Landi et al 1997a, 2002).
In conclusion, flexor and extensor tendon defects are usually linked to severe
traumatic events. The priority list which includes survival of the limb, resurfacing skin
defects and simultaneous or secondary reconstruction of tendon defects deserves, in our
experience, equal attention on both the volar and the dorsal aspects of the hand.
Case 1
CG: 25-year-old male. Open lesion at the dorsum of the left hand initially treated
elsewhere.
Figure 1-1
The patient was unable to actively extend the wrist and
long fingers.
Figure 1-2
Postoperative radiographs: extensor carpi radialis longus
(ERLC) has been reconstructed by a tendon graft taken
from extensor carpi radialis brevis (ERBC). The graft has
been anchored to the third metacarpal by an anchoring
device.
Figure 1-3 The stiffness of the MP joint of the index

finger was due to an unrecognized fracture
dislocation.
Figure 1-4
Corresponding X-ray.
Figure 1-5
The joint has been replaced by a pyrocarbon prosthesis.
Figures 1-6, 1-7

At 1 year follow-up, the patient is unable to actively
extend the index finger.
Figures 1-8, 1-9

One slip of EDM has been tranferred to the extensor
apparatus of the index finger. The transfer has been
prolonged by a tendon graft harvested from palmaris
longus.
Case 2
MIG: 12-year-old-female. Crush injury at little finger of the right hand. Lesion of flexor
profundus was left untreated during the emergency setting.
Figure 2-1
Preoperative clinical picture.
Figure 2-2
Extensive fibrosis of the flexor apparatus.
Figure 2-3
The silicone rod has been inserted and the retinacular
system reconstructed by three pulleys.
Figure 2-4
Intraoperative passive range motion.
Figures 2-5, 2-6

Clinical follow-up at 3 years.
Figures 2-7, 2-8

The active extension of toes is within the normal range and
is provided by EDB.
Case 3
CG: 36-year-old male. Crush injury of the left hand. A Swanson spacer was used in the
emergency setting to replace the MP joint.
Figure 3-1
Clinical picture showing the impossibility of flexing the
finger.
Figure 3-2
Preoperative X-ray.
Figure 3-3
Intraoperative picture showing extensive damage of the
tendon sheath.
Figure 3-4
Interruption of the flexor apparatus required a staged
flexor tendon repair.
Figure 3-5
The silicone rod has been inserted and A2–A4 pulleys
reconstructed.
Figures 3-6, 3-7

Favourable outcome at 2 months.
Case 4
DA: 30-year-old male. Lesion of the flexor apparatus of the index finger of the right
hand.
Figure 4-1
Intraoperative finding
Figure 4-2
A preliminary suture was carried out in the palm between
the flexor superficialis and the corresponding flexor
profundus.
Figure 4-3
The wound became contaminated by Micrococcus sp.
during the rehabilitation phase.
Figure 4-4
The staged flexor grafting procedure was completed
according to the Paneva–Holevich technique.
Case 5
DR: 11-year-old male. Subcutaneous rupture of flexor profundus of the middle finger of
the right hand.
Figure 5-1
Figures 5-2, 5-3

Positive outcome following a single stage tendon grafting
procedure to the profundus through the intact sublimis.
Palmaris longus was used as a graft source.
Case 6
MM: 26-year-old male. Crush injury of the right hand treated elsewhere.
Figures 6-1, 6-2

Subankylosis of DIP joint was present in association with
disruption of the flexor apparatus of the long finger.
Figure 6-3
Stage one of the technique as described by Hunter has
been carried out. A two pulley system has been
reconstructed. The initial purpose was to simply re-
establish a ‘superficialis finger’.
Figures 6-4, 6-5

Follow-up at 1 year showed an unpredictably favourable
result as active flexion of the DIP joint was obtained. The
joint stiffness was overcome by the active motion of the
tendon graft.
Case 7
DRL: 52-year-old female. Sequelae of crush injury of the left hand. A two-stage
technique flexor tendon reconstruction has been carried out. A fixed ‘hook deformity’
was finally established.
Figure 7-1
Pre-generative clinical finding.
Figure 7-2
Complete passive motion of the little finger can be
achieved.
Figure 7-3
The technique of TATA.
Figure 7-4
Intraoperative flexion of the little finger.
Figures 7-5, 7-6

Follow-up at 1 year.
Figure 8-1
Preoperative picture.
Case 8
PG: 20-year-old male. Sequelae of a sharp injury in the palm. The patient, a policeman,
was unable to flex the index finger of the dominant hand.
Figure 8-2
Intraoperative finding: a flexor tendon minigraft to the
flexor profundus was harvested from the corresponding
superficialis.
Figures 8-3, 8-4

At 1-year follow-up the patient was able to resume all the
previous vocational and other activities.
Case 9
BS: 36-year-old male. RTA with exposed metacarpal fractures (right hand) initially
treated elsewhere.
Figure 9-1
Infection and secondary rupture of the extensor tendons.
Figure 9-2
Preoperative radiograph.
Figure 9-3
Release of the MP joint was carried out.
Figure 9-4
A forearm composite flap including PL and FRC was
performed.
Figures 9-5, 9-6

Follow-up after 5 months. The donor site was unsightly
and a limited (~40°) active range of motion was recorded.
Figure 9-7
Clinical outcome at 10 years. Complete independence in
DLA was accomplished.
Case 10
MG: 54-year-old female. Thermal injury with a crush component at the dorsum of the
hand. The wound was debrided and skin resurfaced with a groin flap.
Figures 10-1, 10-2

Figure 10-3
ECRB to EDC (2nd–3rd) and ECU to EDC (4th–5th)
tendon transfers have been carried out.
References
Amadio PC, Wood MB, Cooney WP, Bogard SD (1988) Staged flexor tendon
reconstruction in the fingers and hand, J Hand Surg 13(A):559–68.
Baker GL (1995) Braided plantaris tendon as extensor tendon graft, Contemp Orthop
30:111–13.
Bevin AG, Hothem AL (1978) The use of silicone rods under split-thickness skin grafts
for reconstruction of extensor tendon injuries, Hand 10:254–8.
Biesalski K (1910) Ueber sehnenscheidenauswechslung, Deutsche Med Wochnschr
36:1615–18.
Bishop AT, Topper SM, Bettinger I (1996) Flexor mechanism reconstruction and
rehabilitation. In: Surgery of the Hand and Upper Extremity. Peimer CA, ed.
McGraw-Hill: USA, Vol. I: 1143–61.
Boyes JH (1950) Flexor tendon grafts in the fingers and thumb: an evaluation of end
results, J Bone Joint Surg 32(A):489–95.
Boyes JH (1997) Flexor tendon grafts in the fingers and thumb: An evaluation of end
results. In: Tendon and Nerve Surgery in the Hand. Hunter JM, Schneider LH, Mackin
EJ, eds. CV Mosby: USA, 410–16.
Bruser P, Poss T, Larkin G (1999) Result of proximal interphalangeal joint release for
flexion contractures: midlateral versus palmar incision, J Hand Surg 24(A): 288–94.
Bunnell S (1918) Repair of tendons in the fingers and description of two new
instruments, Surg Gynecol Obstet 26:103–10.
Burton R, Melchior JA (1982) Extensor tendons—Late reconstruction. In: Operative
Hand Surgery. Green PD, Hotchkiss RN, Pederson WC, eds. Churchill Livingstone:
USA, Vol. II:1988–2019.
Caroli A, Adani R, Castagnetti C, Pancaldi G, Squarzina PB (1993) Dorsalis pedis flap
with vascularized extensor tendons for dorsal hand reconstruction, Plast Reconstr Surg
92(7):1326–30.
Chaplin DM (1973) The vascular anatomy within normal tendons, divided tendons, free
tendon grafts and pedicle tendon grafts in rabbits, J Bone J Surg 55(B):369–89.
Carrol RE, Basset AL (1963) Formation of tendon sheath by silicone-rod implants, J
Bone Joint Surg 45(A):884–5.
Cautilli D, Schneider LH (1995) Extensor tendon grafting on the dorsum of the hand in
massive tendon loss, Hand Clin 11:423–9.
Dolphin JA (1965) Extensor tenotomy for chronic boutonniere deformity of the finger:
Report of two cases, J Bone J Surg 47(A):161–4.
Doyle JR, Blythe WF (1975) The finger flexor tendon sheath and pulleys: anatomy and
reconstruction. In: AAOS Symposium on Tendon Surgery in the Hand. CV Mosby: St
Louis, 81–7.
Foucher G (1997) Flaps and tenolysis for metacarpophalangeal joint stiffness. In: Joint
Stiffness of the Upper Limb. Copeland S, Gschwerd N, Landi A, Saffar P, eds. Martin
Dunitz: London, 237–41.
Fowler SB (1959) The management of tendon injuries, J Bone J Surg 41(A):579–80.
Gelberman RH, Seiler JG III, Rosenberg AE (1992) Intercalary flexor tendon grafts: A
morphological study of intrasynovial and extrasynovial donor tendons, Scand J Plast
Graham WC (1947) Flexor tendon grafts to the fingers and thumb, J Bone Joint Surg
29(B):553–9.
Heuck G (1881) Ein beitrang zur sehnenplastik, Zentralbl Chir 9:289–92.
Hiroshi Y, Inada Y, Masaki S, Tamai S (1996) Radial forearm flap with vascularized
tendons for hand reconstruction, Plast Reconstr Surg 98:328–33.
Hou SM, Liu TK (1993) Vascularized tendon graft using lateral arm flap; 5 microsurgery
cases, Acta Orthop Scand 64:373–6.
Hume EL, Hutchinson DT, Jaeger SA, Hunter JM (1991) Biomechanics of pulley
reconstruction, J Hand Surg 16(A):722–8.
Hunter JM, Salisbury JM (1971) Flexor tendon reconstruction in severely damaged
hands: a two-stage procedure using a silicone Dacron reinforced gliding prosthesis
prior to tendon grafting, J Bone Joint Surg 53(A):829–58.
Hunter JM, Salisbury RE (1997) Flexor tendon reconstruction in severely damaged
hands. A two-stage procedure using a silicone-dacron reinforced gliding prosthesis
prior to tendon grafting. In: Tendon and Nerve Surgery in the Hand. Hunter JM,
Schneider LH, Mackin EJ, eds. CV Mosby: USA, 498–517.
Hunter JM, Mackin EJ, Byron PM, Jeager SH (1997) Reconstruction of flexor tendon
function and strength. In: Tendon and Nerve Surgery in the Hand. Hunter JM,
Schneider LH, Mackin EJ, eds. CV Mosby: USA, 523–42.
Ichioka S, Harii H, Yamda A, Sugiura Y (1994) Tendinocutaneous free flap transfer to
cover an extensive skin-tendon defect of the dorsum of the hand, J Trauma 36:901–3.
Iselin F (1973) The flag flap, Plast Reconstr Surg 52:374.
Iselin F (1975) Preliminary observations on the use of chemically stored tendinous
allografts in hand surgery, In: AAOOS Symposium on Tendon Surgery in the Hand.
Mosby: St Louis.
Javaid M, Cormack GC (2003) Anterolateral thigh free flap for complex soft tissue hand
reconstructions, J Hand Surg 28B:21–7.
Karev A (1984) The ‘belt loop’ technique for the reconstruction of pulleys in the first
stage of flexor tendon grafting, J Hand Surg 9(A):923–32.
Karev A, Stahl S, Taran A (1987) The mechanical efficiency of the pulley system in
normal digits compared with a reconstructed system using the ‘belt loop’ technique, J
Hand Surg 12(A):596–601.
Kleinman WB (1996) Post-traumatic PIP flexion contractures. Correspondence
Newsletter 8 July, American Society for Surgery of the Hand.
Lai CS, Lin SD, Yang CC, Chou CK (1991) Adipofascial turn-over flap for complicated
dorsal skin defects of the hand and finger, Br J Plast Surg 44:165–9.
Landi A (1973) Lesioni esposte dei tendini della mano: valutazione biologica del danno e
criteri terapeutici, Riv Chir Mano 11:57–64.
Landi A, Altman FP, Pringle J, Sayers DCJ (1980a) Oxidative enzyme metabolism in
rabbit intrasynovial flexor tendons. III, J Surg Research 29:287–92.
Landi A, Monteleone M, Caroli A (1980b) Il lembo libero Dorsalis Pedis nella chirurgia
della mano: prime esperienze personali , Riv Chir Mano 27:311–14.
Landi A, Cugola L, Luchetti R, Soragni O (1985) I reimpianti pluridigitali di mano,
Giorn Ital Ortop 11:53–63.
Landi A, Luchetti R, Soragni O, Desantis G (1991) The distally-based posterior

interosseous island flap for the coverage of skin loss of the hand, Ann Plast Surg
27:527.
Landi A, Barca F, Santi A, Tartoni L (1995) Gait analysis of the donor foot in
microsurgical reconstruction of the thumb, Foot Ankle Int 16:201.
Landi A, Saracino A, Caserta G, Esposito M (1997a) Complex tenolysis of the hand. In:
Tendon and Nerve Surgery in the Hand. Hunter JM, Schneider LH, Mackin EJ, eds.
CV Mosby: USA, 456–85.
Landi A, Caserta G, Saracino A, Facchini MC (1997b) Stiffness of the thumb. In: Joint
Stiffness of the Upper Limb. Copeland SA, Gschwend N, Landi A, Saffar P, eds.
Martin Dunitz: London, 277–87.
Landi A, Busa R, Caserta G (2002) Joint stiffness. In: Bone and Skin Disorders. Tubiana
R, Gilbert A, eds. Martin Dunitz: London, 64–91.
Lange F (1900) Uber periostale sehnenverpflanzungen bei lahmungen, Munchener Med
Wochnchr 47: 486–90.
LaSalle WB, Strickland JW (1983) An evaluation of the two-stage flexor tendon
reconstruction technique, J Hand Surg 8(A):263–72.
Lin GT, Amadio PC, An KN (1989) Biomechanical analysis of finger flexor pulley
reconstruction, J Hand Surg 14(B):278–86.
Lister GD (1979) Reconstruction of pulleys employing extensor retinaculum, J Hand
Surg 4:461–8.
Littler JW (1947) Free tendon grafts in secondary flexor tendon repair, Am J Surg
74:315.
Lundborg G (1976) Experimental flexor tendon healing: a new concept of tendon
nutrition and intrinsic healing mechanism, Hand 8:235–41.
Mayer L (1916a) The physiological method of tendon transplantations: I, Surg Gynecol
Obstet 22:182.
Mayer L (1916b) The physiological method of tendon transplantations: II, Surg Gynecol
Obstet 22:198.
Mayer L (1916c) The physiological method of tendon transplantations: III, Surg Gynecol
Obstet 22:472.
Mayer L, Ransohoff N (1936) Reconstruction of the digital tendon sheath. A contribution
to the physiological method of repair of damaged finger tendons, J Bone Joint Surg
18(B):607–16.
Milgram JE (1960) Transplantation of tendons through preformed gliding channels , Bull
Hosp Joint Dis 21:250–95.
Nishida J, Amadio PC, Bettinger PC, An KN (1998) Flexor tendon pulley interaction
after pulley reconstruction: a biomechanical study in a human model in vitro, J Hand
Surg 23(A):665–72.
Nishida J, Amadio PC, Bettinger PC, An KN (1999) Flexor tendon-tendon sheath
interaction after tendon grafting: a biomechanical study in a human model in vitro, J
Hand Surg 24(A):1097–102.
Okutsu I, Ninomiya S, Hiraki S (1987) Three-loop technique for A2 pulley
reconstruction, J Hand Surg 12(A):790–8.
Osborne G (1960) The sublimis tendon replacement technique in tendon injuries, J Bone
Joint Surg 42(B):647.
Osborne G (1975) Redemption operations for flexor tendon injuries. In: Proceedings of
the Second Hand Club. Stack HG, Bolton H, eds. British Society for Surgery of the
Hand: London.
Osterman AL, Paksima N (1997) Flexor tendon injuries and repair in children. In:
Paneva E (1987) Two-stage tenoplasty: Results. In: Tendon and Nerve Surgery in the
Hand. Hunter JM, Schneider LH, Mackin EJ, eds. CV Mosby: USA, 270–81.
Parkes A (1971) The lumbrical plus finger, J Bone Joint Surg 53(B):236–9.
Peyrot JJ (1886) Transplantation chez l’homme d’un tendon empruntè a un chien.
Guerison avec retablissement partiel de la fonction, Bull Mem Soc Chir Paris 12:356–
61.
Pulvertaft RG (1956) Tendon grafts for flexor tendon injury in the fingers and thumb, J
Bone Joint Surg 38(B):175.
Quaba AA, Davison PM (1990) The distally-based dorsal hand flap, Br J Plast Surg
43:28.
Ramesh R, Britton JM (2000) A retinacular sling for subluxing tendons of the first
extensor compartment. A case report, J Bone Joint Surg 82(B):424–5.
Rozmaryn LM (1995) Tendon graft reconstruction of extensor hood deficits with
subluxation, J Hand Surg 20(A):841–3.
Russel RC, Van Beek AL, Wavak P, Zook EG (1981) Alternative hand flaps for
amputation and digital defects, J Hand Surg 6(A):399.
Sakellarides HT (1987) Severe injuries of both flexor tendons in ‘no man’s land’ with
excessive scarring and severe flexion contractures: Treatment with silicone rod and
tendon grafting – A follow-up of 60 cases. In: Tendon Surgery in the Hand. Hunter
JM, Schneider LH, Mackin EJ, eds. CV Mosby: USA, 265–9.
Salamon A, Biro V, Vamhidi L, Trombitas K, Jozsa L (1997) Histology and
ultrastructure of the normal tenosynovium and pseudosheath in chickens and humans.
In: Tendon Surgery in the Hand. Hunter JM, Schneider LH, Mackin EJ, eds. CV
Mosby: USA, 489–97.
Schneider LH (1997a) Staged tendon reconstruction: History and current perspective. In:
Schneider LH (1997b) Isolated flexor digitorum profundus injury: Treatment by tendon
grafting. In: Tendon and Nerve Surgery in the Hand. Hunter JM, Schneider LH,
Mackin EJ, eds. CV Mosby: USA, 400–3.
Schneider LH, Hunter JM (1993) Flexor tendons: late reconstruction. In: Operative Hand
Surgery, 3rd edn. Green DP, ed. Churchill Livingstone: New York, 1853–924.
Schneider LH, Hunter JM, Fietti VG (1987) The flexor superficialis finger: A salvage
procedure. In: Tendon Surgery in the Hand. Hunter JM, Schneider LH, Mackin EJ,
eds. Mosby CV: USA, 312–16.
Seiler JG, Gelberman RH (1997) Tendon grafting to the synovial spaces of the hand: A
biologic basis for the selection of the donor tendon . In: Tendon and Nerve Surgery in
the Hand. Hunter JM, Schneider LH, Mackin EJ, eds. CV Mosby: USA, 404–9.
Snow JW (1973) Use of a retrograde tendon flap in repairing a severed extensor tendon
in the PIP joint area, Plast Reconstr Surg 51:555–8.
Sukkar SM, Saulis AS, Dumainian GA (2002) Radial forearm skin with flexor carpi
radialis muscle: a useful composite free flap, Ann Plast Surg 49:486–9.
study and a clinical technique, Br J Plast Surg 32:170.
Tomaino NM, Plakseychuk A (2000) Two-stage extensor tendon reconstruction after
composite tissue loss from the dorsum of the hand, Am J Orthop 29: 122–4.
Tsuge K (1988) A Comprehensive Atlas of Hand Surgery. McGraw-Hill: Milan.
Tubiana R (1960) Greffes des tendon flechisseurs des doigts et du pouce. Technique et
resultats , Rev Chir Orthop 46:191–214.
Tubiana R (1965) Incision and technics in tendon grafting, Am J Surg 109:339–45.
Tubiana R (1997) Tendon grafting: A historical perspective, In: Tendon and Nerve
Surgery in the Hand. Hunter JM, Schneider LH, Mackin EJ, eds. CV Mosby: USA,
397–9.
Vermeylen J, Monballiu G (1991) The use of the extensor indicis proprius as a
vascularised tendon graft. A preliminary report, J Hand Surg 16(B):185.
Wehbe MA, Mawr B, Hunter JM (1986) Two-stage flexor-tendon reconstruction: ten-
year experience, J Bone Joint Surg 68(A):752–61.
Weilby A (1968) Flexor tendon grafts: results in 95 cases, Acta Orthop Scand 39(3):369–
75.
Wilson RL (1985) Flexor tendon grafting, Hand Clin 1:97–105.
17
When to use vascularized tendon transfers
and how is the digital flexion sliding system
supposed to work?
Jean C Guimberteau
Introduction
In classes III, IV, or V of Boyes’ classification are patients who have already undergone
multiple operations with skin scarring, joint stiffness and severe flexion contracture
deformity.
Treatment of such problems has consisted of amputation, distal arthrodesis or tendon
grafting, often in two stages. The latter approach, however, allows neither adequate
nutrition to the graft (leading to repeated failures) nor results in consistently satisfactory
function, and even then, the ultimate range of active movement requires a minimum of 6
months to achieve.
Fifteen years ago, we abandoned this traditional approach in favour of a more rapid
and physiologic technique in which the tendon is regarded not as a simple string to
transmit forces but as a living organ. The single stage operation using an island
vascularized flexor tendon transfer allows earlier discharge return to home and to work
and reduces the cost in socioeconomic terms. However, before we adopted this approach
we had to modify our outlook towards tendon physiology and anatomy.
Armed with new information from dissections on fresh treated cadavers and more than
300 reverse ulnar flaps, the time has come to confirm some anatomical truths and to
finally discard certain preconceived ideas. Some traditional basic concepts seem to be at
variance with anatomical reality and should be changed.
Physiological conclusions
There is no histological difference between the paratendon and the carpal sheath. The
ancient term—paratenon—thus includes the whole of the peripheral sliding system called
multimicrovascular collagenic dynamic absorbing system (MCDAS) made of billions of
microvacuoles and a fibrous frame. The MCDAS is the proximal histological
continuation of the perimysium profundus layer and it differentiates functionally to
become the digital sheath (Fig. 1).
In fact it is the same structure but viewed differently from different aspects under
different mechanical circumstances. As soon as an external or internal factor increases
internal pressure,
Figure 1
Figure 2
the distribution changes in a megavacuole with a selective blood pedicle in protected

areas. The notion of a piston machine mechanism is false and obsolete. This analytical
concept must be replaced by a systemic concept. Contrary to the holistic aspect there is
no difference between the vascular system in tendons and a peripheral synovial vascular
system without communication.
Anatomical conclusions
Vascularization is continuous and permanent (Fig. 2). There is no area without blood
supply. Tendon, epitenon and MCDAS are supplied by the same vascular system.
Tendons are not hypovascular. The digital canal is an efficient adaptation of the MCDAS
as a megavacuole with vincula system. So the digital and carpal sheaths do not have the
same sliding system. All these observations are innovative in that they introduce a new
concept. The SLIDING UNIT composed of the tendon and its surrounding sheaths (Fig.
3).
From now on, Potenza’s principle, tendon adhesions and reconstruction of the digital
sheath using a silicone rod should give way to newer principles.
• A tendon only has optimal functional value when it is surrounded by its original
When to use vascularized tendon transfers 295
sliding sheath and its vascular supply.
Figure 3
• A tendon only adheres when it is artificially separated from its own sliding sheath, or
when the harmony between the tendon and the sheath has been interrupted.
• A tendon is only one of the intervening elements in the transmission of a force through
the sliding unit.
The method of natural replacement for secondary flexor tendon

salvage
The new principles of tendon physiology introduce a completely new approach to the
problem of reconstruction:
1. The concept of the tendon-sheath couple and the major role of tendon vascularization
with peripheral collagen organization is emphasized.
2. The transfer of a sliding unit composed of a flexor tendon and its surrounding sheaths
in reverse island pedicle manner in one single operation, thus avoiding the two-stage
procedure for secondary repair is proposed, inspired by biological consequences (Fig.
4).
This new technique is used today in clinical cases for the reconstruction of finger flexor
systems in grades III and IV of Boyes’ classification.
Figure 4
Basic principles
1. The tendon can only be conceived as vascularized.
2. The tendon can only be conceived as an element in association with its surrounding
sheaths to form a sliding unit.
In order to conform with these two basic principles, the proposed new technique must
satisfactorily answer three basic questions.
Technical questions
1. Which sliding zone must be used to replace zones I and II, subject to so many
problems and complications?
The mesotenon and its vascular branches provide vascularization of the flexor
tendon and the sliding carpal sheath both extrinsically and intrinsically. The structure
thus transferred is a real sliding structure which already exists in a natural state in
zones III, IV and V.
The principle is to replace the digital sliding zones I and II, the most frequently
reconstructed zone, by the natural sliding zone of the wrist and the palm, i.e. zones III,
IV and V. Because the tendon used for the reconstruction is transferred with its own
sheath, it does not need to adhere to the neighbouring tissue to survive, and any
adhesion formation is reduced, leading to improved functional results. Potenza’s basic
principle of the absolute necessity for adhesion can thus be discarded and the two-
stage procedure is now considered obsolete.
Furthermore, the transferred tendon is a real flexor tendon with all its original
qualities of resistance and flexibility. Technically, the sutures are placed outside the
‘no man’s land’ and the sliding unit, composed of the tendon and the carpal sheath, is
inserted between pulleys A1 and A4.
2. What will be the method of vascularization of the flexion replacement structure?
Vascularization is ensured by a preretinacular mesotenon, with branches issuing from
the ulnar artery.
Anatomical reminder
At the inferior third of the wrist, just before the flexor retinaculum carpi or the annular
ligament, the ulnar artery gives off two or three branches around 1 mm in diameter.
These branches pass through the common carpal sheath towards the superficial flexor
tendons, especially those of the middle finger, the ring finger and the little finger, by way
of a fine transparent mesotenon, which acts as a mesentery. This vascular approach to the
flexor system and the common carpal sheath is made distal to the tendon–muscle
junction, thus permitting the adaptation of the concept of retrograde island transfers to
purely tendinous structures.
This vascularization is one of the principal differences from the radial artery based
flap because it is developed in the tendon zone and not in the muscle zone. Purely
tendinous transfers can be developed founded on the concept of vascularized tendon
island transfers. This certainly represents a fundamental change in the concept of tendon
reconstruction. According to the same principle and using the same surgical technique, it
is possible to carry out not only pure tendinous vascular transfers (most often with the
superficial flexor tendon of the ring finger), but also a cutaneo-tendinous transfer, and
even the triple transfer of skin, tendon and bone.
3. How will this sliding unit be placed into ‘no man’s land’?
Nowadays, the technique of island retrograde forearm transfer is used, to transfer a
forearm or wrist structure which is pedicled on an arterial axis. For retrograde
vascularized tendon transfer, only the ulnar based pedicle is suitable owing to its
distally based palmar point of rotation and to its branch transmission at an exclusively
tendinous level.
Technique
The basie procedure consists of the transfer of the flexor superficialis tendon of the ring
finger to repair any type of tendon defect. Preoperative evaluation includes Allen’s and
Doppler tests to ascertain that the radial artery provides adequate blood supply to the
hand. Angiography of the arm is also advisable (Fig. 5).
A bayonet-shaped incision is first traced and then made on the medial side of the
forearm, the axis of the incision overlying the lateral border of the flexor carpi ulnaris.
The cutaneous branches between the ulnar artery and the skin, emerging from the volar
aspect of the pedicle and which are the principal components of the ulnar forearm flap,
are then carefully isolated. These branches should be divided only when skin transfer is
not required. The ulnar pedicle is then separated from the ulnar nerve on its dorsal
Figure 5
aspect along its whole length from the lower third of the forearm to Guyon’s canal.
Reflection of flexor carpi ulnaris and the ulnar nerve ulnarward and the skin of the
volar surface in a radial direction exposes the preretinaculum area and the carpal tunnel,
which is opened. The small vascular branches running from the anterolateral side of the
ulnar pedicle to the flexor superficial tendons of the fourth and fifth rays are identified
through the transparency of the large mesotendon which begins just before the carpal
tunnel and continues into the common carpal sheath with vascular connections.
The flexor superficialis tendons of the third and fifth fingers are drawn aside, and all
mesotendinous structures and carpal sheath surrounding these two tendons are carefully
dissected free and preserved to accompany the future tendon transfer. A mesotendinous
structure composed of the flexor superficialis of the ring finger is raised, with its carpal
sheath (to permit slight sliding) and its vascular connections from the ulnar pedicle.
These connections, usually comprising two or three small branches on the anterolateral
side and measuring, on average, 0.2–0.5 mm in diameter, are found just before the
proximal edge of the flexor retinaculum.
By means of an incision of the volar digital surface, the flexor superficialis of the ring
finger is divided at the level of the chiasma tendinum. The tendon is divided proximally
at the muscle junction. The tourniquet is released, and a clamping test of the ulnar pedicle
is performed to establish that there is a satisfactory blood supply to the hand through the
radial artery and to the tendon transfer by retrograde flow in the superficial palmar
arcade.
After proximal ligature of the ulnar pedicle, a composite mesotendinous island transfer
20 cm long is raised, as with any reversed forearm flap, and transferred to the distal part
of the hand to provide a complete flexor tendon unit for any finger from the pulp to the
wrist. Like any reversed forearm flap, the transferred unit is pliable and plastic, and in
addition, the blood supply that bathes its intrinsic and extrinsic components is readily
visualized throughout.
The rest of the operation follows conventional principles of tendon surgery. The
tendon area wrapped in the common carpal sheath is laid into the ‘no man’s land’ beneath
the A2 and Ag pulleys, which must be carefully preserved or solidly reconstructed, since
the tendon transfer exposes them to much greater strain than a simple tendon graft. The
transfer is inserted first into the distal phalanx by means of a ‘barbed wire’ suture.
Proximal suture with the distal extremity of the relevant flexor profundus is performed
using Pulvertaft’s method. The tension on the suture is easy to assess and should be
slightly overcorrected in comparison with the other fingers. On completion of the
procedure, a dynamic Kleinerttype splint is applied to allow early movement.
Combined flexor tendon and skin transfer (Fig. 6)

In some cases when the overlying skin is extremely scarred and of poor quality,
particularly at the base of P1 or P2, it would be impossible to replace the flexor tendon
and achieve early motion. Skin of this sort inevitably breaks down or necroses,
compromising the functional result, and therefore, it should be replaced.
In the lower third of the forearm, the ulnar pedicle not only sends branches to the
flexor superficialis tendons but also to the skin. These branches, constantly of excellent
calibre, are easily identified, being close to the mesotenon branches, and allow
simultaneous composite transfer of skin and tendon. Generally the skin island lies
proximal to the mesotenon position. However, due to the pliability and flexibility of these
cutaneous branches, the transfer can be rotated and positioned on the digital surface
Figure 6
without changing the physiologic direction of tendon fibres. This is of fundamental

importance in achieving a good functional result.
Case reports
Case 1
A 40-year-old agricultural worker had undergone two previous operations after complete
division of the flexor superficialis and flexor profundus of the fifth left finger. These
procedures included secondary suture and tenolyses. No pulley reconstruction. Island
reverse vascularized tendon transfer with the flexor superficialis of the fourth finger was
performed. This patient had an
Figure 7
Figure 8
Figure 9
excellent functional result within 45 days. Although preoperatively there was no active
range of movement in flexion, the functional result was a total recovery of motion. The
patient returned to work within 3 months (Figs 7–9).
Case 2
A 33-year-old woman had undergone two former surgical procedures, including two
tenolyses and a palmaris brevis tendon graft, resulting in a fixed flexion deformity of the
little finger at 90°
Figure 10
Figure 11
Figure 12
Figure 13
of flexion in the proximal interphalangeal joint and bowstringing secondary to pulley

collapse. Because of a large skin defect, a composite skin and tendon transfer was
performed. After 50 rehabilitation sessions and application of a night extension splint for
3 months, the functional result was very good (Figs 10–13).
Discussion
The new technique, which is now our standard procedure for cases in Boyes’ class III or
IV, using a mesovascular tendon island, is likely to set the trend for future flexor tendon
surgery because the requisite tendon reconstruction can be carried out in one operation.
As compared with all other tendon graft techniques, the advantages of this techniques are
as follows.
It makes use of a living tendon island on a thin mesotenon with vascular branches,
providing a perfect blood supply to all areas, both extrinsic and intrinsic. It thus avoids
adhesions and improves the vascularity of the surrounding tissues. Since the transfer is a
real flexor tendon and not a simple myotendinous structure, it retains flexibility, pliability
and resistance, and allows the correct tension to be achieved. Because vascularization is
preserved, all sheaths are retained. The paratenon and in particular the carpal sheath
(which is transposed into ‘no man’s land’) retain the unrestricted gliding movement of
the tendon.
The length of the tendon transfer is approximately 18–20 cm. This allows easy
reconstruction of any type of flexor tendon defect from the pulp to the carpal area. Thus
the tendon anastomoses are not under tension and lie outside ‘no man’s land’. Because of
the very distal rotation point and the mesotenon plasticity and versatility, the placement
and anchoring need attention but can be performed without difficulty. The operation is
performed in the same way as a classic reverse flow radial or ulnar forearm flap. The
mesotendinous vascular branches are anatomically constant, and the dissection will take
approximately the same amount of time as a reverse flow forearm skin flap
(approximately 90 minutes).
This is a one-stage procedure allowing retention of all gliding surfaces, which means
that recipient bed preparation by a pseudosynovial sheath using a silicone rod is
unnecessary. However, all pulleys have to be repaired carefully because it has been found
that the traction exerted by this type of tendon is greater because the resistance is less.
Compared with the other forearm transfers and their potential for composite transfers, the
only one that allows simultaneous transposition of skin, bone and tendon is the radial
forearm flap. However, this type of flap does not allow transfer of the common carpal
sheath and the flexor tendon because the radial pedicle supplies them only at the
myotendinous level and its rotation point is too proximal. The new technique of
composite transfer described in this chapter is specifically confined to the ulnar vascular
system and may conveniently be knows as the ULNAR TRAIL SYSTEM.
The main disadvantage of our technique is the need to transect the ulnar pedicle.
However, in our experience with more than 450 cases of all varieties of ulnar transfers,
no undesirable longterm effects such as paraesthesia or functional deficits have been
encountered 1 year after surgery. It is nevertheless preferable to restore arterial continuity
by either a venous graft or a vascular prosthesis 2 mm in diameter.
Results
It is very difficult to evaluate the results after complex tendon reconstruction operations
because the variables involved are too numerous (age of the patient, procedures used,
type of injury, accompanying nerve, bone, or vascular injuries, and especially associated
skin problems). Many systems of evaluation have been proposed. We prefer the Tubiana
system because it is based on methodology centred on proximal interphalangeal joint
movement, which in our opinion displays the principal effects of the flexor tendon
transfer. The arithmetical addition of degrees between extension and flexion compared
with the hypothetical maximum amplitude, while not distinguishing between
metacarpophalangeal joint and proximal interphalangeal or distal interphalangeal joints,
would seem inadequate for this sort of salvage situation. There is rarely a significant
alteration of metacarpophalangeal joint movement.
It is obvious that in these cases the principal aim is to restore effective and useful
function, including grip, and especially to attain recovery of good proximal
interphalangeal joint movement. The Tubiana evaluation gives specific evaluation of
proximal interphalangeal joint function, which is readily assessed by comparing P2
position to the metacarpal bone in the same digit. In this study, all patients were classified
into four groups preoperatively, and the criteria used were largely based on Boyes’
classification (modified by Tubiana) though more importance was given to preoperative
skin condition. Our strategy is defined by the skin quality. Since there is early
mobilization (3 days postoperatively), it is very necessary is to avoid skin dehiscence or
necrosis.
Our study was divided into two series: Series A: 21 patients, all previously operated on
at least twice (excluding emergency procedures) and corresponding to class II (3 cases),
class III (8 cases) and class IV (10 cases) in whom flexor superficialis transfers were
performed. Series B: 25 patients corresponding to class IV in whom composite skin flap
and flexor superficialis transfers were performed.
In series A, 21 patients were analysed according to the Tubiana classification, four
excellent (1 group II, 2 group III, 1 group IV), six very good (4 group III, 2 group IV), six
good (2 group II, 2 group III, 2 group IV), three medium (2 group IV) and two poor (2
group IV). Great improvement was achieved in 76% of patients.
In series B, 25 patients were analysed, five very good, 11 good, three medium and six
poor.
The results show that 66% of these extreme salvage flexor tendon situations were
greatly improved. The technique also produces favourable trophic changes. Finger skin
becomes more supple and sensitive, joints are less stiff and are mechanically active, and
flexion is improved. All this testifies good biologic recovery. Overall, 15 patients (64%)
achieved an excellent, very good, or good result; this compares with an average figure of
55% in results published for similar cases in series using the two-stage procedure with or
without a silicone rod.
What is definite is that our results have improved by a better understanding of the
flexor tendon biology and the restored gliding mechanism. This new technique seems to
give better functional performance and reduces time off from work.
Conclusions
We present a completely new approach to flexor tendon reconstruction for major salvage
surgery. Use of island flexor tendon, vascularized by ulnar mesotenon, with all its gliding
surfaces intact, seems to be a major advance in dealing with adhesions and has the added
merit of being a one-stage procedure. These types of ulnar vascularized tendon or tendon
and skin transfers with multiple applications and good functional results could set a trend
in tendon reconstructive surgery.
Toe-to-finger free flexor tendon transfer for digital flexion

reconstruction (In collaboration with J. Bakhach)
Based on this ‘idea’ of pedicled tendon transfer, which however may not be useful in
cases with extended injury of the entire flexion mechanism, we have transferred the
flexor mechanism of the second toe as a free composite flap and repaired ‘en bloc’ and in
a single operation, the flexor
Figure 14
tendons, digital theca and palmar plates of a long finger. According to our technique, this
composite flap is based on the medial plantar vessels and contains both flexor tendons of
the second toe with their digital sheaths and pulleys. The results of an anatomical study
which was carried out describe the different types of vascular basis of the flap and
confirm the safety of the transfer (Figs 14–17).
Figure 15
Figure 16
Figure 17
Human allotransplant of a digital flexion system vascularized on the

ulnar pedicle
In light of this experience, the idea of a simultaneous tendon and pulley vascularized
allotransplant gradually developed, especially since several clinical cases using non-
vascularized entire flexor tendon complex homografts, originally performed by E
Peacock, were reported previously to produce conflicting functional results. These can be
explained, doubtlessly, by an immunologic response to tendon cell components although
there is little or no antigenicity to the collagen tendon structure. These tendon homografts
were non-vascularized, taken from cadavers and either stored by deep freezing or
preserved in Cialit.
Introduction of cyclosporine in 1980 changed the indications and improved success
rates of allovascularized transplantations with the use of low, non-toxic maintenance
doses for these relatively weak antigenicity response organs. Ideas regarding tissue
compatibility have led to more simplified techniques over the past few years.
Specific characteristics of the anatomical structure of the ulnar vascular network,
previous experience in homotendon grafts, the use of low dose cyclosporine, and the
necessity to improve functional results have all combined to produce a successful human
vascularized allotransplant of a complete digital system by microsurgery.
Transplantation technique (from a cadaver)

The original procedure, based on our knowledge of the ulnar blood supply of the flexor
superficialis, especially of the ring finger, is described.
Preoperative preparation. The donor is in a dorsal position. The arm is in
hyperabduction to facilitate cooperation with the other surgical teams. A tourniquet is put
on just before aorta clamping. First, the heart and liver are removed. These procedures
take at least 2 hours. Then the nephrectomy can be accomplished, and during this period,
the hand surgeon can perform this procedure.
Dissection. The incision proceeds longitudinally along the forearm, starting above the
anterior edge of the flexor carpi ulnaris and turning 90° along the fold of the wrist before
following the interthenar fold and adopting a zigzag pattern across the palm, according to
the Brunner technique, as far as the digital extremity. The different branches of the ulnar
pedicle in the forearm are identified. Those supplying the skin and connected with the
forearm anterior superficial venous network (usually two or three of differing calibre
situated on the anterior side of the pedicle) and the tendons (usually three on the lateral
side, one at the tendon-muscle junction of the flexor digitorum sublimis of the fourth
finger, and two others of approximately 0.3 mm diameter at the entrance to Guyon’s
canal) are then selected. The two branches supplying the joint and the cubital bone, as
well as the hypothenar and dorsal branches are ligated.
The flexor digitorum sublimis of the finger is separated from the flexors digitorum
sublimis of the middle finger and the small finger and is dissected at the tendon-muscle
junction. All the tendon-nourishing pedicles coming from the ulnar pedicle, as well as all
adjacent mesotenons, are carefully preserved. The carpal tunnel and Guyon’s canal are
opened, and the ulnar pedicle is separated from the ulnar nerve as far as the motor branch.
All vascular and nerve structures on the ulnar side of the palm are identified and
dissected, particularly the fourth common palmar digital artery.
Vascular ligatures or clamps are placed at the point of division on the ulnar pedicle of
the false deep branch, the deep branch, and the collateral branch of the fifth artery on the
ulnar and radial sides while conserving the collateral branch of the fourth artery on the
ulnar side. The superficial palmar arcade is then clamped and transected between the
third and fourth opened, especially near the volar, surface of the interphalangeal joints.
On the radial side of the ring finger, the procedure is the same. We also leave the
collateral pedicle on the radial side in the transplant.
To avoid opening the sheath and thus inducing tendon adhesions, we leave the flexor
profundus in place. The use of ulnar veins to ensure venous return has been abandoned,
and the veins of the superficial forearm network, which are more suitable for
microsurgery, are preferred. At the wrist, the largest of the ulnar arterio-venous skin
branches is dissected as well as a 3-cm segment of a superficial vein connected to it. This
vein will provide venous return if the ulnar veins are inadequate.
The only remaining link between the structure to be transplanted and the donor’s hand
is now the ulnar pedicle itself. The tourniquet is released, and vascularization is
immediate.
The functional unit composed of the profundus and superficialis tendon flexors and
the entire pulley system is then separated from the digital bone skeleton using a medial-
side access and passing behind the vascular nerve collateral branch, which must be
included in the transplant. This dissection is made in the subperiosteal plane along the
skeleton of P1, P2 and P3, but the tendon sheath is not opened.
The ulnar pedicle is then ligated above the branch supplying the skin, and the
transplant is placed in a sterile plastic container containing refrigerated serum at 40°C.
Implantation. Preparation of the recipient site. The site is cleared of any sclerotic
tendinous structures and all traces of the pulleys. Only the collateral vasculonervous
pedicles are retained. The incision is enlarged at the ulnar pedicle and is dissected at the
wrist, and the artery and ulnar veins are well individualized. A vein from the anterior side
of the forearm is dissected, and the proximal end of the flexor digitorum profundus of the
finger to be repaired is identified.
Insertion of the transplant. This insertion is performed by means of barbed wire
sutures integrating the lateral structures of the transplant into the periosteal edge of the
recipient bed on both sides at the base of P1, the head of P1, the base of P2 and the head
of P2. At P3, the anchorage is to the bone. Perioperatively, it is easy to check the
functioning of the transplant by applying traction to the proximal end of the flexor
digitorum sublimis.
Anastomoses. The proximal extremity of the flexor digitorum sublimis and profundus
is passed under the superficial palmar arch of the recipient hand to avoid vascular
compression before being sutured to the distal end of the recipient flexor digitorum
profundus as described by Pulvertaft. Extremities of the ulnar artery were anastomosed
end-to-side. The dorsal ulnar veins are also anastomosed with recipient anterior forearm
veins. Total ischaemia time was 3 hours in our case.
Functional results
In our case, a very good functional result was obtained 4 months later. The wrist swelling
disappeared little by little, and since the patient had no active motion preoperatively, the
functional result with a range of motion in flexion of 80° in the proximal interphalangeal
joint and no extension defect and a range of motion in flexion of
Figure 18
Figure 19
Figure 20
Figure 21
55° in the distal interphalangeal joint with an extension defect of 35° was considered
excellent (Figs 18–20).
The average total active flexion almost equalled the available range of passive motion.
This finger is now very functional and perfectly adapted.
Conclusions
This technique is a step towards a new type of reconstruction in hand surgery. It can be
used not only for the flexion system, but also for bone and joints. For the moment,
medicolegal constraints are severe, and exacting criteria must be met before any
transplant can be performed. Such constraints may diminish over time, and techniques of
repair and reconstruction such as those described here will be able to develop freely for
use in selected patients. Despite the success of this technique, it should be reserved for
complex cases where conventional techniques are not possible.
References
Boyes JH (1950) Flexor tendon grafts in the fingers and thumb: an evaluation of end
results, J Bone Joint Surg 32A:489.
Guimberteau JC, Panconi, B (1990) Recalcitrant nonunion of the scaphoid treated with a
vascularized bone graft on the ulnar artery, J Bone Joint Surg 72:88.
Guimberteau JC, Goin JL, Panconi B, Schumacher B (1988) The reverse ulnar artery
forearm island flap in hand surgery: About 54 cases, Plast Reconstr Surg 81:925.
Guimberteau JC, Goin JL, Panconi B, Schumacher B (1989) Tendon ulnar artery island
flap in hand surgery: technique, indications, Eur J Plast Surg 12:12.
Guimberteau JC, Baudet J, Panconi B, Boileau R, Potaux L (????) Human allotransplant
of a digital flexion system vascularized on the ulnar pedicle: A preliminary report and
1 year follow-up of two cases, Plast Reconstr Surg 89:11–35.
Guimberteau JC, Kleinert H, Verdan CI (2001) New Ideas in Hand Surgery. Island
Vascularized Flexor Tendons Transfers, The Sliding System. Aquitaine Domaine
Forestier
Hunter JM (1985) Tendon salvage and the active tendon implant: A perspective.
Symposium on flexor tendon surgery, Hand Clin 1:J8J.
Littler JW (1947) Free tendon grafts in secondary flexor tendon repair, Am J Surg 74:315.
Lundborg G, Holm S, Myrhage R (1980) The role of the synovial fluid and tendon sheath
for flexor tendon nutrition , Scand J Plast Reconstr Surg 14:99.
Paneva Holevitch E (1972) Résultats du traitement des lésions multiples des tendons
fléchisseurs des doigts pargreffe effectuée en deux temps, Rev Chir Orthop Repar
58:481.
Potenza AD (1963) Critical evaluation of flexor-tendon healing and adhesion formation
within artificial digital sheath, J Bone Joint Surg 45A:1217.
Strickland JW (1989) Flexor tendon surgery: 2. Free tendon graft and tenolysis, J Hand
Surg J4B:358.
Tubiana R (1986) Traité de la Chirurgie de la Main, vol. 3. Masson: Paris.
Verdan CE (1975) The decades of tendon surgery. In: American Academy of Orthopedic
Surgeons Symposium on Tendon Surgery. Mosby: St Louis.
Compound transfers
18
Composite tissue transfer in the upper
extremity
Günter Germann and Simone Brüner
Introduction
Compound defects in the upper extremity are most frequently caused by high impact
injuries such as contusion trauma or gun-shot injuries. Rare causes are tumour resections,
necrotizing infections or tissue necrosis following extravasation of cytostatic agents or
irradiation. Most severe injuries involving vascular trauma can threaten survival of the
upper limb (Pulcini et al 2000).
Before the introduction of microsurgical techniques into the clinical routine, complex
defects frequently ended in amputation. Although microvascular repair and the
introduction of free tissue transfer had already improved the survival rate of severely
injured upper extremities, major advances occurred when the concepts of ‘onestage
reconstruction’, ‘emergency free flaps’ and ‘chimeric free flaps’ were introduced into
clinical practice (Germann et al 1999, Koshima 2001, Nisanci et al 2002, Rogachefsky et
al 2002).
There is no generally used classification system for complex tissue defects in the
upper extremity. For the purpose of this chapter, we have designed a simple descriptive
classification system:
1. Extended skin and soft tissue defects—Type A defect.
2. Skin and soft tissue defects involving muscles and tendons—Type B defect.
3. Skin and soft tissue defects involving neurovascular structures—Type C defect.
4. A–C + segmental bone defects—Type D defect.
The introduction of free tissue transfer into plastic surgery opened the door to an entirely
new world of reconstructive procedures. Large defects could be resurfaced with a single
procedure thereby reducing treatment time, treatment cost and patient morbidity. The
latissimus dorsi muscle either as a pure muscle or as a myocutaneous flap soon became
the workhorse of reconstructive procedures, because of its large surface area, reliable
anatomy and large vascular calibre (Rogachefsky et al 2002).
A wide variety of free flaps were introduced in the years following, including
myocutaneous flaps such as the tensor fascia lata flap (TFL); pure cutaneous flaps such as
the scapular flap; fascio-cutaneous flaps such as the lateral arm flap or the dorsalis pedis
flap; and muscle flaps such as the gracilis flap or the rectus abdominus flap. Increasing
knowledge about the anatomical properties of the flaps led to the introduction of new
concepts. Nerve reconstructions of muscle flaps facilitated functional muscle transfer to
replace lost muscles or nerve function. Harvesting side branches of vascular pedicles
Composite tissue transfer in the upper extremity 313
allowed ‘flow-through flaps’ with the reconstruction of vascular defects (Germann et al

1999, Horch et al 1999, Pulcini et al 2000, Chun and Sterry 2001, Koshima 2001,
Sauerbier et al 2001, Tropet et al 2001, Fairbanks and Hallock 2002, King et al 2002,
Nisanci et al 2002, Rogachefsky et al 2002, Wei et al 2002a, Yang et al 2002).
Prefabrication of flaps either by implantation of arterio-venous fistulae under defined
skin territories, or by prefabrication via vascularized fascia transfer and pre-expansion
were the next step in tailoring the reconstructive strategies to specific requirements of the
defects. Pre-expanded flaps were introduced to increase the surface area of commonly
used flaps. The variety of refinements and modifications resulted in the most recent
development, the so-called chimeric or designer flaps. These flaps include several
components of tissue raised on one vascular pedicle, and are customized to the
requirements of the defect. These flaps are frequently used as osteocutaneous flaps in
facial reconstruction. The introduction of these type of flap into the treatment strategies
for complex upper and lower extremity defects have promoted the concept of ‘onestep
reconstruction’ (Koshima et al 1993, Fairbanks and Hallock 2002).
Reconstructive strategy
Traditionally, compound defects either caused by tumour resection or by trauma, were

reconstructed in a multistage approach. After the defect was reconstructed with
appropriate means (pedicle flap, free flap), functional structures were reconstructed in
several stages. Nerve grafts were usually planned after an interval of 6 weeks to 4
months. Tendon transfers were frequently performed at even later stages. Bony defects
were reconstructed by multiple graft procedures, with usually the first procedure carried
out at the time of nerve reconstruction. This concept led to prolonged duration of
treatment, multiple hospital stays and delayed social and professional reintegration
(Germann et al 1999, Tropet et al, 2001).
After Marco Godina’s pioneering work on the lower extremity, there was clear
evidence that early reconstruction, ideally within 5–7 days post trauma, resulted in
superior treatment results. The concept was quickly adopted by leading hand and plastic
surgery centres. The reconstructive concept fundamentally changed from delayed staged
reconstruction to ‘as early and as complete as possible’. Alternately the concept of
‘emergency free flap’ was introduced, originally meaning immediate soft tissue
reconstruction after appropriate debridement (Tropet et al 2001).
The terminology in the literature is confusing, since free flaps performed within 48
hours postadmission are also called immediate free flaps by some authors. Summarizing
the literature, a one-stage reconstruction following trauma consists of:
• radical debridement at the time of admission
• preserving all functional structures whenever possible
• removal of all tissue of questionable viability
• immediate reconstruction—as far as infrastructure, logistics, availability of
microsurgical teams, situation of the patient, etc. allow
• scheduled second look 48 hours post trauma with immediate one-stage reconstruction,
if indicated.
In selected cases of severe contusion injuries or necrotizing infections, consecutive

second looks may be scheduled.
Several reasons justify a scheduled second look with concomitant reconstruction:
1. No study to date has shown that immediate reconstruction yields superior results
compared to scheduled early post primary reconstruction.
2. These injuries are typically admitted after regular hours when limited manpower is
available, even in large units.
3. Busy hand and microsurgical units frequently have a load of other emergency cases.
4. The surgeons already have a full working day behind them and are not in ‘top shape’.
5. Operating theatre capacity may be limited.
6. Best results can be expected with a well rested team and a patient in a perfect
condition, i.e. all potential morbidities are excluded as far as possible.
Selection of flaps
Type A and B defects

As mentioned above, flap selection depends largely on the type of defect and availability
of flaps. This also includes the position of the patient, i.e. some flaps cannot be harvested
in certain patient positions. Extensive soft tissue defects involving large surface areas or
resulting in deep cavities together with superficial defects are usually reconstructed with
chimeric flaps containing several cutaneous or muscle flaps based on the same vascular
pedicle. A frequently used combination is the latissimus dorsi muscle combined with the
serratus muscle or the serratus fascia (Chun and Sterry 2001). Alternatively,
Figure 1
(a) Soft tissue defect of the dorsum of the hand after
abrasion injury. The paratenon was lost and the extensor
tendons exposed. Destruction of the metapopharyngeal
joint of the little finger. (b) Soft tissue reconstruction with
a scapular skin flap and a parascapular fascia extension to
serve as new gliding tissue for the extensor tendons.
the subscapular arterial system offers several more options for cutaneous flaps, such as
the parascapular flap, the scapular flap or the myocutaneous latissimus dorsi flap. There
are various combinations possible, which fulfil most of the requirements (Germann et al
1999, Chun and Sterry 2001, Fairbanks and Hallock 2002).
Another situation where only soft tissue components are required is when the transfer
of gliding tissue together with skin territories is indicated, as is sometimes encountered in
defects of the dorsum of the hand with exposed tendons or following tendon
reconstructions (Fig. 1). Several options are available for these situations, such as a
combined deep and superficial temporal artery flap (TPF), a combined serratus and
serratus fascia flap, a skin flap from the scapular system including a fascial extension, or
for larger defects any combination of a flap from the subscapular arterial system with a
portion of the serratus fascia.
In extensive soft tissue defects, multicomponent flaps are occasionally required. The
selection of the components mostly depends on the size of the defect. As in the examples
discussed above, the most frequently used source of large combined flaps is the
subscapular system where the individual components of the flap can be customized to
match the length and the width of the defect. (Germann et al 1999) Alternatively, the
lateral circumflex femoral artery system can be used. This system allows inclusion of the
TFL, the vastus lateralis, the rectus femoris and the anterolateral perforator skin flaps.
In defects with concomitant segmental loss of nerve or vascular structures ‘one-flap’
reconstructions are still possible in selected cases (Type C defects). Several flaps can be
used as flow-through flaps for simultaneous arterial reconstruction. The classic example
is the radial forearm flap with its large calibre vessel, but flaps from the subscapular
system can also be
Figure 2
Type B defect: (a) compound soft tissue defect with loss of
superficial flexor muscles and third degree open ulnar
fracture—medial aspect. (b) Lateral aspect showing the
severe crush defect of the extensor muscle group. (c)
Despite the open fracture, plate osteosynthesis for stable
internal fixation under well-vascularized soft tissue
coverage is performed. (d,e) Soft tissue reconstruction with
a large muscular latissimus dorsi flap plus skin graft after
tendon repair and osteosynthesis. The flap was the best
solution in this case due to the large surface area required.
The residual function was very satisfying.
used when the branch to the serratus muscle or the circumflex scapular artery is harvested
with the pedicle, and is of sufficient calibre (Fig. 2) (Germann et al 1999, Chun and
Sterry 2001, Fairbanks and Hallock 2002)
Type C defects
The repair of neural defects with vascularized components of chimeric flaps is rarely
possible. Neural structures that are suitable to bridge gaps
Figure 3
Type C defect: (a) Severe high-voltage injury with loss of
the soft tissue envelope of both forearms, muscle substance
and tendons, and bilateral involvement of median and
ulnar nerves. (b) Parascapular flap to the right forearm
with transfer of remaining tendons to achieve residual
function; partial nerve reconstruction. (c,d) Function of
both hands approximately 3 months after parascapular flap
to the left hand. (e) Thermoplastic splint for dynamic
motion protocols after tendon transfer.
in the ulnar or the medial nerve are not part of the commonly used compound tissue
transfers, where usually only small calibre cutaneous nerves are included. However, in
microsurgically transferred fillet flaps from amputated body parts, a major nerve may be
occasionally included. Soft tissue defects with simultaneous loss of tendon structures
(Type B, C defects) have been occasionally treated in the past with a dorsalis pedis flap
as a tendocutaneous unit. However, the donor site morbidity with respect to the aesthetic
appearance and the functional impairment led to a significant decline in the use of this
flap. Complex tendon–cutaneous defects are, at present, usually reconstructed by soft
tissue reconstruction, and a free non-vascularized transfer of the long extensor tendon
system from the dorsum of the foot (Fig. 3). Tendon strips for the repair of isolated
tendon defects can be included into many conventional free flaps, for example the lateral
arm flap, the anterior thigh flap, and the TFL flap (Saleh et al 1999, Omokawa et al 2001,
Wei et al 2002b).
Type D defects
Several options are available for defects involving skeletal structures. The size of the
cutaneous defect and the length of the bony gap determine the type of flap. The
combination of a short bony defect with a large soft tissue deficit is usually an indication
for a flap from the subscapular system including a segment of the medial or lateral
scapular rim (Fig. 4). Longer defects of the radius or the ulna are an indication for an
osteocutaneous fibula flap. The fibula is the ideal bone for the reconstruction of a tubular
bone such as the radius. Bony consolidation occurs within 6–8 weeks, and after several
years there will be almost no radiological difference between the transplanted fibula and
the original radius. However, it has to be emphasized that the cutaneous island that can be
raised with the fibula is limited in size. Soft tissue volume can be increased by
simultaneously harvesting the soleus muscle, but this makes the dissection significantly
longer and more tedious (Küntscher et al 2001). In cases of large soft tissue defects with
a long segmental osseous defect two free flaps are probably the procedure of choice.
Figure 4(a–c)
Figure 4(d–g)
Type D defect: (a) Severe crush injury with segmental
bone loss, laceration of median nerve, loss of radial artery
and severe semicircular soft tissue loss. (b) Intraoperative
situation after nerve and tendon repair and vascular
interposition vein graft to the radial artery. (c) Raised
multicomponent scapular/parascapular flap with a segment
of the scapula. (d) Plate osteosynthesis for stable internal
fixation. (e) Flap is wrapped around the wrist and forearm.
Vascular anastomosis to ulnar artery and cephalic vein.
(f,g) Satisfactory function after approximately 6 weeks.
Segmental defects
These are the most severe types of defects. Although, depending on the level of injury,
many functional structures may be involved, one-stage reconstruction with a composite
tissue transfer may still offer a solution. Free tendon or nerve grafts can be incorporated
into soft tissue bone and muscle reconstruction, and have high success rate under stable,
well vascularized soft tissue coverage. Stable internal or external fixation allows for early
rehabilitation, and yields significantly better long-term results than primary amputation or
multistage reconstruction where many secondary or tertiary procedures have to be
performed in scarred tissue (Saleh et al 1999, Tropet et al 2001, Fairbanks and Hallock
2002).
Conclusion
The concept of one-stage reconstruction has revolutionized reconstructive strategy

following trauma or tumour resection. The development of composite tissue transfer with
the option of including all types of tissue required has facilitated this quantum leap in
reconstruction procedures. Today, almost all defects can be reconstructed in a single
operation, as long as debridement or tumour resection is sufficient. The wide variety of
flaps available permits the reconstruction of most complex defects while simultaneously
limiting donor site morbidity. Profound knowledge of the anatomy and of the possible
options of combinations provide the reconstructive microsurgeon with a large
armamentarium of flaps that allows customized treatment for the individual patient.
References
Chun JK, Sterry TP (2001) Latissimus dorsi musculocutaneous flap based on the serratus
branch with microvascular venous augmentation, J Reconstr Microsurg 17:95–8.
Fairbanks GA, Hallock GG (2002) Facial reconstruction using a combined flap of the
subscapular axis simultaneously including separate medial and lateral scapular
vascularized bone grafts, Ann Plast Surg 49:104–8; discussion:108.
Germann G, Bickert B, Steinau HU, Wagner H, Sauerbier M (1999) Versatility and
reliability of combined flaps of the subscapular system, Plast Reconstr Surg
103:1386–99.
Horch RE, Stark GB (1999) The rectus abdominis free flap as an emergency procedure in
extensive upper extremity soft-tissue defects, Plast Reconstr Surg 103:1421–7.
King TW, Gallas MT, Robb GL, Lalani Z, Miller MJ (2002) Aesthetic and functional
outcomes using osseous or soft-tissue free flaps, J Reconstr Microsurg 18:365–71.
Koshima I (2001) A new classification of free combined or connected tissue transfers:
introduction to the concept of bridge, siamese, chimeric, mosaic, and chain-circle
flaps, Acta Med Okayama 55: 329–32.
Koshima I, Yamamoto H, Hosoda M, Moriguchi T, Orita Y, Nagayama H (1993) Free
combined composite flaps using the lateral circumflex femoral system for repair of
massive defects of the head and neck regions: an introduction to the chimeric flap
principle, Plast Reconstr Surg 92:411–20.
Küntscher MV, Erdmann D, Homann HH, Steinau HU, Levin SL, Germann G (2001)
The concept of fillet flaps: classification, indications, and analysis of their clinical
value, Plast Reconstr Surg 108:885–96.
Nisanci M, Selcuk I, Duman H (2002) Flow-through use of the osteomusculocutaneous
free fibular flap, Ann Plast Surg 48:435–8.
Omokawa S, Mizumoto S, Fukui A, Inada Y, Tamai S (2001) Innervated radial thenar
flap combined with radial forearm flap transfer for thumb reconstruction, Plast
Pulcini G, Ottaviani GM, Lancini GP, Biasca F, D’Adda F, Pouche A (2000) Vascular
trauma of the upper extremities, G Chir 21:394–8.
Rogachefsky RA, Aly A, Brearley W (2002) Latissimus dorsi pedicled flap for upper
extremity soft-tissue reconstruction, Orthopedics 25:403–8.
Saleh M, Yang L, Sims M (1999) Limb reconstruction after high energy trauma. Br Med
Bull 55:870–84.
Sauerbier M, Erdmann D, Bickert B, Wittemann M, Germann G (2001) Defect coverage
of the hand and forearm with a free scapula-parascapula flap, Handchir Mikrochir
Plast Chir 33:20–5.
Tropet Y, Garbuio P, Obert L, Jeunet L, Elias B (2001) One-stage emergency treatment
of open grade IIIB tibial shaft fractures with bone loss, Ann Plast Surg 46:113–19.
Wei FC, Celik N, Chen HC, Cheng MH, Huang WC (2002a) Combined anterolateral
thigh flap and vascularized fibula osteoseptocutaneous flap in reconstruction of
extensive composite mandibular defects, Plast Reconstr Surg 109:45–52.
Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH (2002b) Have we found an
ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps, Plast Reconstr
Surg 109:2219–26; discussion:2227–30.
Yang JY, Tsai FC, Chana JS, Chuang SS, Chang SY, Huang WC (2002) Use of free thin
anterolateral thigh flaps combined with cervicoplasty for reconstruction of postburn
anterior cervical contractures, Plast Reconstr Surg 110:39–46.
19
Free functioning muscle transfer
Alain Gilbert and Vittore Costa
In cases of severe muscle paralysis or destruction there are often few surrounding
muscles left for tendon transfers. These are the most common indications for
microsurgical muscle transplantations. Muscle transfers have been used for a long time
for the coverage of large or infected defects. Although the addition of function in muscle
transfer seems logical, it is not easy as several factors complicate the procedure such as
the presence/absence of a good donor nerve and the tension of the muscle belly.
Tamai et al (1970) had experimentally proved in dogs that the muscle transplant could
remain vital and functioning. Following this, reports of clinical cases were published in
several parts of the world (Shanghai 1976, Ikuta et al 1976, Harii et al 1976, Manktelow
and McKee 1978, O’Brien 1977, Gilbert, 1981).
However, even 25 years later, there are very few large series with long follow-up. This
may be due to few indications and a certain scepticism regarding this technique.
Muscles used for free functioning transfer
For transplantation of a muscle several conditions need to be fulfilled:

1. The defect created by removal should be easily filled.
2. It should be a rather long muscle with, if possible, a tendon on each extremity.
3. It should have only one neurovascular hilus or at least a major one.
4. The excursion of the muscle should be as long as possible, to obtain maximum
movement.
5. Its cross-section should be thick enough to produce sufficient force (the maximum
tension in mammals is 4 kg/cm2 of cross-sectional area; Carlson, 1974).
Several muscles have been used:
Gracilis
This muscle is most frequently used. It is long (30–40 cm), with a strong terminal tendon.
It is not too bulky and can be fitted into a limb without additional skin cover. It has a
single proximal motor nerve, coming from the obturator nerve, that measures 6–8 cm.
The only drawback is its vascular supply: there is a dominant proximal pedicle but also a
secondary pedicle going to the middle part of the muscle and a small distal pedicle; since
this distal pedicle is never necessary, there may sometimes be problems when the middle
pedicle is
Figure 1
The gracilis muscle. The main proximal neurovascular
pedicle.
ligated. If, after this ligation, the distal part of the muscle becomes dark (congested), it
may be necessary to anastomose the vein from the middle pedicle. This was necessary in
two cases out of 20.
Pectoralis major
This is a large muscle with a single vascular pedicle, but it has several motor nerves, is
very bulky, and its removal creates a severe defect.
Pectoralis minor
This is small and weak and has been used only in facial reconstruction. It is difficult to
raise, as it is deep to pectoralis major but can be isolated on one or two pedicles.
Latissimus dorsi
This is a very well known muscle, long, strong, with a single vascular and motor pedicle.
Its removal does not create a severe defect. However, some techniques of lengthening the
latissimus dorsi with the gluteal aponeurosis allow its transplantation up to the fingers.
There are few indications for using a free latissimus dorsi muscle transfer in the upper
extremity.
Gastrocnemius
This is a very strong muscle (the strongest in the body), easy to raise, with a proximal
neurovascular pedicle. The sural nerve as a vascularized nerve graft (useful in
Volkmann’s contracture) and/or the overlying skin can be raised at the same time. The
defect created is compensated by the soleus. Its main drawbacks are its bulk and very
short excursion.
Free functioning muscle transfer 325
Other muscles that have been used are rectus femoris (it has several vascular hila);
extensor carpi radialis brevis (too small); extensor digitorum brevis from the foot (whose
vascularization is very delicate and has been used mainly for the face).
Figure 2
In some cases, it is necessary to use the second pedicle.
Surgical technique
The surgical technique for gracilis transfer for elbow flexion is as follows. With the
patient lying supine, the thigh is prepared including the pubis area. The muscle can be
felt, at least in thin patients, by feeling its contraction during flexion–extension of the
knee. This positioning is important if a combined muscle and skin flap is to be used: the
area covering the muscle is very narrow and if the skin incision is not precisely
positioned, the vitality of the skin flap may be impaired. Finding the muscle is not always
easy as all the adductor muscles have the same direction and size. However, among these
muscles, the gracilis is relatively thin and has a large proximal pedicle.
Once the muscle is found, dissection is easy. On the medial aspect, the three pedicles
can be found:
• The distal pedicle is small and systematically sacrificed.
• The middle pedicle is cut but with the vessels kept long, in order to be accessible if
needed.
• The proximal major pedicle is dissected carefully. The vascular pedicle is followed
until the trunk of the perforator where the diameter of the artery is 1.5 mm. The nerve
has an upward direction towards the inguinal ligament. It originates from the obturator
nerve.
Figure 3
(a) A 6-year-old patient. The arm was previously
replanted. The biceps is destroyed. (b) The gracilis is
transplanted with neurovascular anastomoses. The nerve
from the biceps is used. (c,d) Active elbow flexion after 8
months.
This motor nerve gives one or two branches to the muscle before the main hilus. The
existence of these branches that provoke separate contraction of some groups of muscle
fibres has led some authors (Mankletow 1988) to suture them separately and expect an
individual contraction to reconstruct a different movement (thumb + fingers).
Figure 4
(a) Proximal long standing paralysis of the brachial plexus.
(b) Gracilis transplantation on the intercostal nerves. (c)
Strong elbow flexion, lifting 2 kg.
Once the pedicle is dissected (6–8 cm for vessels, 8–10 cm of nerve), the muscle can
be detached; before detaching it, it is important to mark the length with regular stitches,
in order to fix it with the exact tension. At this moment it is useful to inject the patient
with a muscle relaxant to avoid contraction, once it is be detached. The distal tendon is
cut and, protecting the pedicle, the proximal fibrous attachment to the pubis. It is then
possible to cut the pedicle and transfer the muscle to the upper extremity.
The muscle is placed in the arm which is widely exposed. It will be fixed proximally
to the coracoid process or to the pectoralis major aponeurosis. The nerve is sutured to the
donor nerve, usually the sural nerve placed 1 year before (taken from the pectoralis major
nerve on the contralateral side). The size matches well and there should be no tension.
The artery is sutured usually with a branch of the profundus humeral artery; the venous
suture connects the vein to a superficial vein. The revascularization of the muscle is
assessed, particularly the venous drainage of the distal third. If after 10–15 minutes it is
dark and seems congested, the vein from the middle pedicle is sutured.
Then the distal tendon is fixed with the elbow in acute flexion, using the stitches
placed before to control the tension. It is usually fixed to the biceps tendon. After closure,
the elbow is immobilized in flexion for 6 weeks.
Surgical technique for transplantation in the forearm after Volkmann’s

contracture
There are some differences in the forearm.
• The gracilis is usually too long. It is possible to use another shorter muscle
(gastrocnemius, latissimus) or fix the gracilis higher in the arm.
• The distal fixation is different. The tendon is sutured to the deep flexors and a special
technique allows simultaneous positioning of the thumb.
• It is usually possible to use a local nerve. The anterior interosseus nerve is often
separated at its origin and can be used.
Figure 5
(a) Volkmann’s contracture with destruction of the flexor
muscles in a 10-year-old child. (b) Transplantation of the
medial gastrocnemius with the sural nerve. (c,d) Limited
flexion–extension.
• A flap may be needed as the forearm is often scarred.
Personal series
Between 1977 and 2001, 39 free muscle transplantations were done in 38 patients, for
various aetiologies. Only 31 were done following traumatic destruction or paralysis of
muscles. One patient had a postoperative haematoma and necrosis of the muscle; he
subsequently had a second gracilis transfer to the arm.
Twenty-four cases were followed-up for a maximum of 12.4 years and a minimum of
11 months (average 4.7 years). The aetiologies of these were traumatic brachial plexus (n
= 15); obstetrical brachial plexus (n = 3); and Volkmann’s contracture (n = 6).
Gracilis was used most often (20 times) but we used also gastrocnemius (three times)
and extensor carpi radialis brevis (once) in the forearm. There were 15 reconstructions of
elbow flexion, seven reconstructions of finger flexion and 2 extensor reconstructions. The
criteria used for assessment were: joint ROM and MMT, and the modified scale for end-
result evaluation (Dellon et al 1974, Mackinnon and Dellon 1988).
The results showed that 12 patients had muscle function >M3 and 12 <M3. The results
are easier to assess in the arm for an elbow reconstruction secondary to paralysis than in a
forearm after Volkmann’s contracture. In the latter case, the associated nerve paralysis,
intrinsic wasting, and stiffness will have a deleterious
Figure 6
(a) Young paraplegic with complete brachial plexus. The
gracilis is transferred using cross-chest pectoralis major
nerve neurotization. (b) Elbow flexion after 1 year.
effect on the result, even with excellent muscle contraction.

For elbow flexion reconstruction, the donor nerve used was the upper pectoralis nerve
from the contralateral side (13 times) and twice the sternomastoid nerve from the same
side. Both of the latter had poor results with weak muscle contraction and no function.
The contralateral pectoralis nerve was used in two stages. In the first stage, the upper
nerve was isolated and sutured to the end of the sural nerve. The nerve was passed
subcutaneously, anterior to the chest to the upper arm. At this level, a small incision
allowed us to find the nerve end and mark it with a metal clip. After 3 weeks of
immobilization, the progression of nerve regeneration was followed with the Tinel sign.
When tapping the nerve over the chest the patient felt a slight tingling over the thorax on
the donor site. Usually, after 1 year, the regeneration was considered complete and the
second stage of muscle transplantation was possible.
For reconstruction of finger flexion or extension, the anterior interosseus nerve was
used seven times and twice a contralateral graft from the pectoralis nerve was used.
Discussion
Since the first reports on clinical muscle transplantation in 1976, few series have been
published.
In 1988, Manktelow, using mostly gracilis, reported the results of his first 12 transfers
for the forearm. Ten of these cases had good results. Akasaka et al in 1991 showed that in
17 cases of rectus femoris transplantation for elbow flexion, eight of the 11 cases
assessed had resulting function >M3. In wrist extension surgery, they had performed 29
transfers in conjunction with elbow flexion. They found that nine cases had regained M3
function after 1 year. Chuang et al (1993) stated that in a series of 17 patients, using
intercostal nerve transfers, seven had good results (>M3).
Groting et al (1990), used gracilis and tensor fascia lata in 12 patients with satisfactory
results (M4) in 11 cases. Berger and Brenner (1995) used a free latissimus dorsi (8 times)
for elbow reconstruction after brachial plexus paralysis. They found an average of 1–2 kg
of power against resistance.
Doi et al (1993) suggested using free muscle transfers for the combined reconstruction
of two functions, i.e. elbow flexion and fingers flexion or elbow flexion and wrist
extension. They operated 46 patients (58 muscles) of which 31 had had post-traumatic
loss. The donor nerves were the accessory nerve or intercostal nerves. They claimed that
with a double muscle transfer or a double function, single muscle transfer, the results are
good, allowing useful function in completely paralysed patients. Ercetin (1994) showed
that in transplanting gracilis muscle for Volkmann’s contracture, he could obtain active
flexion of the fingers in 23 cases out of 28.
Although these series are few in number, they all demonstrate the feasibility of
vascularized muscle transfer. The results vary from 40% to 70%. Useful results were
acheived depending on various factors such as:
• A good donor nerve is necessary. In cases of brachial plexus paralysis, authors have
used several extraplexal neurotizations (sternomastoid nerve, intercostal nerves,
contralateral C7 or pectoralis nerve). These nerves cannot bring axonal influx of the
same quality as an anterior interosseus nerve, or a musculocutaneous nerve.
• Sensation in the hand is very important, not for recovery of the motor nerve but for its
use.
• Associated nerve lesions can impair the result. In finger flexors reconstruction, the
addition of an ulnar nerve paralysis, with claw and lack of thumb adduction will not
allow good function.
Provided these problems can be avoided, the procedure is reliable and can give some very
good results.
References
Akasaka Y, Hara T, Takahashi M (1991) Free muscle transplantation combined with

intercostals nerve crossing for reconstruction of elbow flexion and wrist extension in
brachial plexus injuries, Microsurgery 12:346–51.
Al-Qattan M (2001) Severe traumatic soft-tissue loss in the antecubital fossa and
proximal forearm associated with radial and/or median nerve palsy: nerve recovery
after coverage with a pedicle latissimus dorsi muscle flap, Ann Plast Surg 46:125.
Berger A, Brenner P (1995) Secondary surgery following brachial plexus injuries,
Microsurgery 16:43.
Brooks M, Seddon HJ (1959) Pectoral transplantation for paralysis of the flexor of the
elbow , J Bone Joint Surg (Br), 41B:36.
Bunnell S (1951) Restoring flexion to the paralytic elbow, J Bone Joint Surg (Am)
33A:566.
Carlson, FD, Wilkie DR (1974) Muscle Physiology. Prentice Hall: Englewood Cliffs, WJ.
Carroll RE, Kleinman WB (1979) Pectoralis major transplantation to restore elbow
flexion to the paralytic limb, J Hand Surg 4:501–7.
Chinese Medical Journal (1976) Free muscle transplantation by microsurgical
neurovascular anastomoses, Chin Med J 2:47–50.
Chuang DC, Epstein MD, Yen MC et al (1993) Functional restoration of elbow flexion in
brachial plexus injuries: results in 167 patients (excluding obstetric brachial plexus
injuries), J Hand Surg (Am) 18:285.
Chuang DC, Carver N, Wei FC (1996) Results of functioning free muscle transplantation
for the elbow flexion, J Hand Surg (Am) 21:1071–7.
Clark JM (1946) Reconstruction of biceps brachii by pectoral muscle transplantation, Br
J Surg 34:180.
Dellon AL, Curtis RM, Edgerton MT (1974) Reeducation of sensation in the hand after
nerve injury and repair, Plast Reconstr Surg 53:297–305.
Doi K, Sakai K, Ihara K et al (1993) Reinnervated free muscle transplantation for
extremity reconstruction, Plast Reconstr Surg 91:872.
Doi K, Marumatsu K, Hattori Y et al (2000) Restoration of prehension with the double
free muscle technique following complete avulsion of the brachial plexus. Indications
and long-term results, J Bone Joint Surg (Am) 82:652–66.
Ercetin O, Akinci M (1994) Free muscle transfer in Volkmann’s ischaemic contracture,
Ann Chir Main 13: 5–12.
Eggers IM, Mennen U, Matime AM (1992) Elbow flexorplasty: a comparison between

latissimus dorsi transfer and Steindler flexorplasty, J Hand Surg (Br) 17:522. Gilbert
A (1981) Free muscle transfers, Int Surg 66:33–5.
Gordon L, David G et al (1993) The serratus anterior free-muscle transplant for
reconstruction of the injured hand: an analysis of the donor and recipient sites, Plast
Gousheh J, Arab H, Gilbert A (2000) The extended latissimus dorsi muscle island flap for
flexion or extension of the fingers, J Hand Surg (Br and Eur) 22B:160–5.
Groting JC, Bunckle HJ et al (1990) Functional restoration in the upper extremity using
free muscle transplantation. Ann Hand Upper Limb Surg 9:98–106.
Gutowski KA, Orestein HH (2000) Restoration of elbow flexion after brachial plexus
injury: the role of nerve and muscle transfers, Plast Reconstr Surg 106:1348.
Harii K, Ohmori K, Torii S et al (1976) Free gracilis muscle transplantation by
microvascular anastomoses Plast Reconstr Surg 57:133–43.
Hohmann G (1918) Ersatz des gelahmten Bizeps brachii durch den Pectoralis major ,
Munchen Wchnschr 65:1240.
Ikuta Y, Kubo T, Tsuge K (1976) Free muscle transplantation by microsurgical technique
to treat severe Volkmann’s contracture, Plast Reconstr Surg 76:413–26.
Ikuta Y, Yoshioka K, Tsuge K (1979) Free muscle graft applied to brachial plexus
injury—case report and experimental study, Ann Acad Med Singapore 8:454–8.
Lange F (1930) Die Epidemische Kinderlahmung. JF Lehmanns Verlag: Munchen.
Lim AYT, Pereira BP, Eng B et al (2001) The long head of the triceps brachii as a free
functioning muscle transfer, Plast Reconstr Surg 107:1746–52.
Mackinnon SE, Dellon AL (1988) Results of nerve repair and grafting. In: Mackinnon
SE, Dellon AL, eds Surgery of Peripheral Nerve, Thieme Medical Publishers: New
York, 117–18.
Manktelow RT (1988) Functioning microsurgical muscle transfer , Hand Clin 4:289.
Manktelow RT, McKee NH (1978) Free muscle transplantation to provide active finger
flexion, J Hand Surg 3:416–26.
Manktelow RT, McKee NH, Vettese T (1980) An anatomical study of the pectoralis
major muscle as related to functioning free muscle transplantation, Plast Reconstr
Surg 65:610.
Manktelow RT, Zuker RM, McKee NH (1984) Functioning free muscle transplantation, J
Hand Surg 9(A):32.
Marshall RW, Williams DH, Birch R, Bonney G (1988) Operation to restore elbow
flexion after brachial plexus injuries, J Bone Joint Surg (Br) 70B:577–82.
Morris SF, Yang D (1999) Gracilis muscle: arterial and neural basis for subdivision, Ann
Plast Surg 42: 630–3.
O’Brien BMc (1977) Microvascular Reconstructive Surgery . Churchill Livingstone:
Edinburgh, 290–305.
Pierce TD, Tomaino MM (2000) Use of the pedicled latissimus muscle flap for upper-
extremity reconstruction, J Am Acad Orthop Surg 8:324–31.
Schenck RR (1977) Free muscle and composite skin transplantation by microsurgical
neurovascular anastomoses, Othop Clin North Am 8:367–75.
Songcharoen P (1995) Brachial plexus injuries in Thailand: a report of 520 cases,
Spira E (1957) Replacement of biceps brachii by pectoralis minor transplant: report of a

case, J Bone Joint Surg (Br) 39B:126–7.
Steindler A (1918) A muscle plasty for the relief of fail elbow infantile paralysis.
Interstate Med J 32:235.
Tamai S, Komatsu S, Sakamoto H et al (1970) Free muscle with neurovascular
anastomoses, Plast Reconstr Surg 46:219–25.
Terzis JK, Dykos RW, Williams HB (1978) Recovery of function in free muscle
transplants by microsurgical neurovascular anastomoses, J Hand Surg 3:37–59.
Terzis JK, Vekris MD, Soucacos PN (1999) Outcomes of brachial plexus reconstruction
in 204 patients with devastating paralysis, Plast Reconstr Surg 104:1221.
Zancolli E, Mitre H (1973) Latissimus dorsi transfer to restore elbow flexion: an
appraisal of eight cases, J Bone Joint Surg (Am) 55A:1265–75.
Zukowski M, Lord J, Ash K et al (1988) The gracilis free flap revisited: a review of 25
cases of transfer to traumatic extremity wounds, Ann Plast Surg 40:141–4.
20
Combined soft tissue and tendon
reconstruction: the dorsum and thenar
regions
Introduction
Soft tissue defects that require tendon and skin reconstruction are not uncommon at the
hand level. This chapter focuses on reconstructing combined defects at two locations: the
dorsum of the hand and the thenar area. In the former, the skin, the tendon and, at times,
the bones are destroyed by frictional or crushing forces. A lack of extension at the
metacarpophalangeal joint is the main limitation. In the thenar area destruction of the
abductor, the opponens and the superficial head of the flexor pollicis brevis by avulsing
forces or burns poses a challenge to the hand surgeon as there is a need to restore cover
and to re-establish opposition.
Compound tendon loss on the dorsum of the hand
Complex dorsal hand injuries where skin and subcutaneous tissue loss is combined with
extensor tendon defects have been traditionally handled by multistaged procedures: skin
grafting or flap coverage followed by tendon grafting or transfer to restore extensor
function at a later stage. However, transfer of compound flaps that include skin and
tendon would provide, in a single stage, a solution to this complex problem.
Multiple donor sites can be ‘found’ if one considers the arterial and venous
distribution throughout the body, where any given pedicle supplies a tridimensional block
of tissue (Taylor and Palmer 1987). However, only two have stood the test of time.
Dorsalis pedis tendinocutaneous flap

Taylor and Townsend (1979) showed that injecting the dorsalis pedis with India ink
stained the paratenon of the extensor digitorum tendons and even ‘within the
infrastructure of the tendon’ the ink was detected under the microscope. They concluded
that the dorsalis pedis flap (McCraw and Furlow 1975) could be expanded to include
several of the extensor tendons and presented a case report of an acute reconstruction.
VilaRovira et al (1985) in corrosion studies further delineated the blood supply to the
extensor digitorum tendons and the skin of the dorsum of the foot. They presented two
cases in which the reconstruction was done secondarily. After those publications other
Combined soft tissue and tendon reconstruction 335
papers have appeared in the literature (Hentz and Pearl 1987, Shen 1989, Caroli et al
1993, Lee et al 1994, Desai et al 1995, Osaka et al 1996, Cho et al 1998).
The flap’s blood supply is based on tiny branches that emerge from the dorsalis pedis
artery and first dorsal metatarsal artery (FDMA) (Man and Acland 1980). The presence
of both is a precondition to ensure reliable nutrition to the flap. Absence of the dorsalis
pedis artery is rare, but anomalies in its course are quite frequent (Cormack and Lamberty
1994) and should be taken into consideration at the time of planning. Additionally, the
presence of a superficial type of FDMA should also be ascertained prior to flap elevation.
If the FDMA can not be included because it lies too deep or is absent (in approximately
20% of cases) (Gilbert 1976, May et al 1977) there is major risk of necrosis of the distal
part of the flap (McCraw and Furlow 1975, Taylor and Townsend 1979, Man and Acland
1980, Cho et al 1999). Angiographic studies are not routinely recommended to assess the
arterial tree because of related morbidity (Upton 1998), and are reserved for situations
where damage or malformations are suspected. Nevertheless, the surgeon can have a
rough idea of the location of the FDMA by using the technique of Banis (1988), in which
the Doppler probe is leant laterally and medially over the first web. We have found this
artifice useful (although not infallible) while raising toe transfers (Piñal et al 2000).
The flap is outlined in the dorsum of the foot centred over the course of the dorsalis
pedis and first dorsal metatarsal arteries. The saphenous vein or any other major
subcutaneous vein is marked to be included with the flap. Dissection commences distally,
by ligating the FDMA. After this the tendons of the extensor hallucis brevis and/or the
appropriate extensor digitorum longus are cut and tagged. Great care should be taken as
the dissection proceeds proximally to include the peritenon and areolar tissues to protect
the blood supply of the harvested tendons, and, at the same time, to preserve the
peritenon of the extensor hallucis longus and the left out tendons, as otherwise the bed
would not be graftable. Particular attention should be paid to the most proximal aspect of
the first web where the FDMA may take off from the deep plantar branch of the dorsalis
pedis instead of from the dorsalis pedis artery proper. If the dissection is carried out from
the sides there is a real risk of severing the FDMA at this level, endangering full flap
survival. To overcome this problem we have found it useful to keep the FDMA under
visual control at all times while dissecting the flap from distal to proximal, and
maintaining the plane of dissection immediately under the artery. Once this difficulty is
overcome the dissection is terminated by cutting the tendons proximally and isolating the
dorsalis pedis–anterior tibial axis in the cleft between the extensor digitorum and hallucis
longus tendons.
Finally the flap is transferred to the hand where tendon tensioning and
revascularization are performed in a standard manner. The bed on the dorsum of the foot
is closed with an intermediate thickness skin graft and a tie-over dressing. A posterior
splint and strict leg elevation is obligatory to ensure a full take.
Cho et al (1999) devised a variant to spare the dorsalis pedis, the flap was nourished
by means of an A-V (arterio-venous) shunt montage. There are several concerns with this
modification including marginal blood supply, and the need for a ‘delay’ operation that
will quite probably not make it popular. In addition, the main drawback of the dorsalis
pedis tendinocutaneous flap, that is, the need for skin grafting the dorsum of the foot,
remains unchanged.
Radial artery forearm flap

Reid and Moss (1983) and Foucher et al (1984) introduced a modification of the reverse
flow radial forearm flap (Song et al 1982, Biemer and Stock 1983) in which the tendons
of the palmaris longus, flexor carpi radialis and brachioradialis were included on the
radial forearm flap. The anatomical relationship of the radial artery and venae comitantes
to the lateral intermuscular septum made this combination feasible. The lateral
intermuscular septum is a fascial condensation attached to the undersurface of the deep
fascia of the forearm bordered by the tendons of the flexor carpi radialis medially and by
the brachioradialis laterally. The vessels from the radial artery travel through this
mesentery to the deep fascia where they form a rich plexus. The palmaris longus which is
located in a duplication of the deep fascia receives its blood supply from this plexus.
Prior to raising the forearm tendinocutaneous flap, the surgeon should confirm the
presence of an intact ulnar artery and adequate blood supply to the hand by Allen’s test.
Consideration should be paid to the possibility of a superficial ulnar artery, as
unawareness of that variant may endanger the blood supply to the hand (Fatah et al
1985). The presence of a palmaris longus tendon should also be checked. Preoperative
angiography is necessary only in those cases where damage to the superficial arch is sus-
pected: reverse flow to the radial artery through the deep palmar arch or other secondary
arches can still permit the use of the ‘Chinese’ flap (Cavanagh and Pho 1992).
Once the defect of the dorsum of the hand is appropriately debrided, a template of the
defect is transposed to the volar forearm. The radial pedicle is identified proximally and
distally and the flap outlined. Care should be taken to include the loose areolar tissue
around the tendons and to include the deep fascia to protect the tiny vessels that supply
the tendons.
The pedicle is dissected distally up to the palmar branch of the radial artery, but if
more pedicle length is required Foucher (Foucher and Merle 1992) has shown that the
palmar branch can be safely ligated and the dissection carried further distally under the
tendons of the anatomical snuff box up to the first web space where the radial artery
communicates with the deep palmar arch. The venous drainage of this flap occurs
through the radial venae comitantes, which unfortunately, have valves that block the
reverse flow. The number of valves is reduced by crossconnections among the venae
comitantes as Lin and co-workers (1984) have shown. However, these connections are
not enough and we have found that the areolar tissue around the pedicle is important to
improve the venous return of the flap; the surgeon should not skeletonize the pedicle
distally to avoid damage to the tiny vessels that act as an alternative pathway to the
venous drainage of this flap (Piñal and Taylor 1993).
After ligating the pedicle proximally the flap is transposed to the dorsum of the hand,
the tendons sutured in the standard fashion and a split thickness skin graft applied to the
donor site.
In reconstruction of combined extensor and skin defects, the flap has gained some
popularity (Yajima et al 1996, Tamai et al 1999) mainly because it is quick to raise, is
located in the same area as the defect, and does not require microsurgery. Unfortunately it
does have some disadvantages: first, the main blood supply to the hand is sacrificed
(Kleinert et al 1989); second, donor aesthetics are poor; and third, the combined
reconstruction tends to be chunky, due in part to the thickness of the flap itself, and in
part to secondary oedema due to insufficient venous drainage that, as stated above, relies
on a complex mechanism (Piñal and Taylor 1993, Nakajima et al 1997). To improve the
latter some surgeons have suggested including just the fascia (Jin et al 1985) and the
vascularized tendons, but the logical approach is to restore normal haemodynamics by
anastomosing a vena comitans to a local subcutaneous vein (Piñal and Taylor 1993).
Decision making for complex losses on the dorsum of the hand

Severe avulsion injuries to the dorsum of the hand where skin and extensor tendon have
been lost creates a significant functional deficit and a major aesthetic challenge: the
dorsum of the hand is, after the face, the most exposed part of the body. The surgeon
should, apart from restoring extensor function at the metacarpophalangeal joint, provide a
cover as close as possible to the anatomical normal: thin pliable skin, with minimal
subcutaneous tissue. A chunky flap (musculocutaneous or otherwise) has no role in
dorsal hand injuries, as ‘aesthetics is an important part of function’.
It is conceded that, without grafting, some extension, at times, will be recovered
because of spontaneous regeneration (Quaba et al 1988). The predictability of this
regeneration is unreliable, however, and it is generally believed that these severe injuries
require tendon reconstruction as well as flap coverage.
It is possible to reconstruct the skin and subcutaneous tissue with a pedicle—or free—
flap, and secondarily to place the tendon grafts. In severe cases an intermediate stage for
Silastic® (Wright Medical, Arlington, TN, USA) rod placement has been recommended
(Cautilli and Schneider 1995), but this multistage procedure has been associated with
longer periods off work, longer recovery time and more operations as compared to single
stage procedures (Sundine and Scheker 1996).
Taylor and Townsend (1979) introduced the vascularized skin tendon compound free
flap. The greatest advantage of using a combined tendon-skin flap is that the tendons are
better vascularized and need not rely on an extrinsic blood supply to heal (Singer et al
1989). Although the concept is appealing, the fact is that similar results have been
reported by simpler procedures—in single or multiple stages (Bevin and Hothem 1978,
Scheker et al 1993, Cautilli and Schneider 1995, Sundine and Scheker 1996).
Furthermore, the donor site can be a source of major unfavourable sequelae. In the case
of the dorsalis pedis there could be delayed healing of the donor site (Fig. 1) and
hyperkeratosis, fissuring, and chronic ulcers with regular shoe wear (Morrison et al 1979,
Tamai and Sakamoto 1993, Babu et al 1994, Lee et al 1994, Balakrishnan 1995, Samson
et al 1998). This prevents its widespread use and the present experience is limited to few
cases by few authors (Vila-Rovira et al 1985, Hentz and Pearl 1987, Caroli et al 1993,
Lee et al 1994, Desai et al 1995, Osaka et al 1996, Cho et al
Figure 1
Donor site 1 month after raising a compound dorsalis pedis
flap. Exposure and partial necrosis of the extensor hallucis
as well as the tarsal bones are evident.
1998, Ian Taylor personal communication 2002). The donor site of the forearm flap is
ugly, for men and women alike, and it requires sacrificing the major blood supply to the
hand (Kleinert et al 1989), which is not desirable particularly after a severe injury to the
hand.
The lateral arm free flap (Katsaros et al 1984, 1991) has been extensively used in hand
reconstruction by the Louisville group (Scheker et al 1987) with impressive results for
combined dorsal injuries such as those we are discussing in this chapter (Scheker et al
1993). In Scheker’s protocol the skin is replaced by a lateral arm flap and in a single
stage the tendons (and if required the bones) are reconstructed. The latter are woven
through the fat of the lateral arm flap, and the patient is put into an immediate protected
mobilization programme.
I have no doubt that at present the best results are obtained with Scheker’s protocol,
and I wholeheartedly recommend it. However, I am not entirely satisfied with the lateral
arm flap as it is at times too bulky particularly in obese, women, and when not harvested
directly over the epicondyle. To overcome this problem we prefer to use a fascial flap, as
it fulfils the requirement of being extra thin, with minimal donor site complications, and
robust blood supply. We have found the lateral arm fascial flap (Yousif et al 1990) most
useful or even the anterolateral thigh fascial flap (Song et al 1984, Gu et al 1991, Wei et
al 2002), but as stated above any fascial flap is appropriate. In patients who want hidden
donor site scars alternative flaps are the dorsalis pedis myofascial flap (Ismail 1990, Piñal
and Herrero 2000), and the temporalis fascial flap (Smith 1980, Brent et al 1985).
Unfortunately, fascial flaps are not thick enough to harbour the extensor tendon grafts
within their substance. As a compromise, we place the tendon grafts under the flap where
the fascia has a gliding surface, recognizing that the ideal position is the fat layer. A
medium thickness or full thickness skin graft from the groin is placed on top of the fascia
(Fig. 2).
Finally, we would stress that, in our experience, to achieve a good functional result the
important point has been, whether the debridement was radical and the reconstruction
immediate (or in few days) and not which flap we selected. Sundine and Scheker (1996)
have shown this beautifully and I cannot agree with them more.
Figure 2
(a) Friction injury to the dorsum of the hand with loss of
extensors to the 2nd, 3rd, 4th and common to the 5th in a
54-year-old. The index was destroyed and only the ulnar
part could be preserved and filleted. (b) Reconstruction of
the extensor tendon and sagittal bands with non-

vascularized flexor tendon grafts taken from the amputated
index. (c) Harvested free anterolateral thigh fascial flap.
Notice the gliding surface underneath the fascia. A skin
graft would be placed directly on top of the fascia. (Inset:
flap design on the thigh, and marked perforators.) (d)
Result 3 months later. (P, descending branch of the lateral
femoral circumflex artery and vein. K, knee arrow points
to the anterosuperior iliac spine.)
Compound thenar mass losses
When a traumatic agent primarily acts on the thenar eminence the damage usually
follows a classic progressive pattern (Fig. 3). In stage 1 there is destruction of the
superficial thenar muscles—abductor pollicis, superficial head of the flexor pollicis. In
stage 2 the opponens pollicis is destroyed too. The adductor pollicis and deep head of the
flexor pollicis are usually spared in this intermediate stage, as the first metacarpal and
trapezium act as a barrier to the progression of the traumatizing agent. However, if the
injuring agent continues to act there will be destruction of the first web muscles—stage 3,
and, at times, thumb amputation—stage 4.
In the first stage (superficial damage) the appropriate treatment is debridement of the
necrotic tissues and application of a skin graft directly over the healthy muscles (or a
local flap). There would be minimal functional impairment as other muscles (opponens
pollicis, abductor pollicis longus) would compensate the loss of the abductor pollicis
brevis and/or flexor pollicis brevis.
In the second stage the abductor pollicis longus compensates (in part) for the absence
of the abductor pollicis brevis but no other muscle would give palmar abduction and
pronation to the thumb. The clinical scenario would be similar to a median nerve palsy
but complicated by the lack of cover. Closure by means of a skin graft cannot be a
definitive treatment as no tendon
Figure 3
Classification of thenar injuries (see text for details).
will glide under a scarred bed. The surgeon has to provide a cover stable enough to resist
shearing forces, and at the same time pliable and well vascularized to provide an
unscarred bed to serve as a gliding path for a tendon transfer. There are many available
sources of motors for opponensplasty (Davies and Barton 1999) and flaps to restore
thenar muscles function, and this is probably the usual way to proceed. Under certain
circumstances a free functioning muscle transplant (FFMT) may be a good alternative: it
provides cover and function at the same time, does not require reeducation (the motor
branch of the median nerve will reinnervate the transfer), and adds to the damaged limb
(sparing donor motors).
The serratus (Mathes and Alpert 1988), the extensor digitorum brevis (Tamai et al
1983, Zhu et al 1985, Mitz 1986) and the abductor hallucis (lbaraki and Kanaya 1995) all
have been used to reconstruct the thenar muscles. The size of the serratus and the need to
apply a skin graft directly over the muscle has not made it popular. Similarly, the
extensor digitorum brevis has fallen into disrepute after several papers reported lack of
strength and excursion in facial reanimation (Terzis and Mersa 2001). The abductor
hallucis is a good replacement for the thenar mass and is covered by fixed glabrous skin.
Abductor hallucis
Ibaraki and Kanaya (1995) first introduced the concept of thenar mass reconstruction
with the abductor hallucis (AH) flap. Others have presented promising results with this
flap (l ik et al 1997, Piñal et al 2002b).
The muscle extends from the medial calcaneal tubercle to the medial sesamoid. It
receives its blood supply from the medial plantar vessels located in the cleft between the
flexor digitorum brevis (FDB) and the AH. The innervation comes from the medial
plantar nerve which sends two or more dominant branches (Hua et al 1995).
The cutaneous portion of the flap is delineated over the muscle, and although a flap of
considerable dimensions can be harvested, we try to keep the skin flap as small as
possible to avoid the risk of donor site problems. The muscle limits are easily identified
except its distal portion where, on the lateral aspect, it is joined by the flexor hallucis
brevis. To avoid any possibility of confusion we begin on the medial aspect going deep to
the muscle and above the periosteum of the navicular and cuneiforms. The deep branch
of the medial plantar artery is ligated and the dissection carried out until the medial
plantar pedicle is located at the lateral edge of the muscle. It is surprising, when
beginning to dissect the flap, how deep the pedicle is located. The surgeon should
remember that there is safety in carefully following the undersurface of the muscle, there
is no structure that may be damaged until the medial plantar pedicle is located in the cleft
between the FDB and AH.
The tendon is identified distally and the fibres of the flexor hallucis brevis dissected
out. Muscle harvesting proceeds quickly now by cutting on the outer limits of the flap
and ligating the vascular pedicle on its distal aspect. At this stage the nerve branches to
the muscle are dissected from the medial plantar nerve by intraneural dissection, and
tracked proximally until a single nerve trunk of sufficient length for late suturing is
obtained. The medial plantar nerve proper need not be sacrificed as recommended by Hua
and colleagues, as this unnecessarily increases the morbidity in the donor site. Finally the
AH is freed from its proximal insertion and the medial plantar artery and vein are
dissected up to the posterior tibial vessels (Fig. 4a). The lateral plantar vessels are ligated
and the AH is pedicled on the posterior tibial vessels ready for transfer (Hua et al 1995,
Ibaraki and Kanaya 1995, I ik et al 1997, Piñal et al 2002b). In an attempt to minimize
morbidity in our most recent case we have directly used as donor the medial plantar
artery, which is large enough for a safe end-to-side anastomosis to the ulnar artery. The
veins can be dissected further proximally, continuing with the posterior tibial venae
comitantes and thus have a venous pedicle of 4 or 5 cm, long enough to go to the dorsal
aspect of the wrist, escaping from the area of injury (Fig. 4b).
The tourniquet is now released and the muscle should be left for at least 20 minutes to
recover. As shown by Manktelov, functioning muscle has a poor ischaemic tolerance and
hence the hand should be fully prepared prior to severing the pedicle. The motor branch
of the median nerve should be dissected proximal to the carpal tunnel for a
straightforward neurorraphy to the motor branch of the AH (Fig. 4c). Once the muscle is
transferred to the hand the nerve is repaired first, then the medial plantar artery is
anastomosed end to side to the ulnar artery in Guyon’s canal (or the posterior tibial artery
to the ulnar artery proximally). The muscle is anchored to the pisiform-medial fascia of
the hypothenar region with resorbable sutures. The tendon of the AH is split and sutured
under tension to the medial aspect of the metacarpophalangeal joint and to the extensor
apparatus as recommended by Brand (Davies and Barton 1999). Finally the venous
anastomoses are completed to any local healthy vein (Fig. 4d).
Donor site closure deserves special attention. The medial plantar nerve is protected by
the flexor digitorum brevis which is mobilized medially and sutured with absorbable
sutures to the periosteum. To assure full take on the donor site we prefer to delay skin
grafting for several days. A posterior splint and rest are advised until full take of the graft.
A compressive stockinet is prescribed for 3 months.
Decision making for complex thenar mass losses

Massive soft tissue destruction of the thenar eminence poses a phenomenal reconstructive
challenge. The surgeon has to use classic techniques such as tendon transfers and ‘newer’
ones such as free flaps, toe to hands, etc.
In stage 2 the decision has to be made between a flap + tendon transfer or an FFMT.
For this decision we take into consideration several factors: the most important being age,
associated trauma, available motors, and fitness. Disappointing results have been reported
when using FFMT in brachial plexus surgery in patients older than 40 years (Doi et al
2000, Nagano 2001). However, this limitation may not apply in thenar reconstruction
where a pure motor nerve is joined to another pure motor nerve, in fact, good results have
been presented in free functioning muscle transfer for facial palsy in patients up to 70
years old (Harii et al 1998). Probably it would be reasonable to avoid functioning muscle
transfer above 55 years. Our experience is, however, limited to young patients. The more
associated damage to the hand, the more we
Figure 4
(a) Operative picture while harvesting the abductor
hallucis. Arrows point to nerve branches to the muscle
isolated in a common trunk after intraneural dissection of
the medial plantar nerve (*). A hollow arrow points to the
medial plantar artery. (Inset: corresponding panoramic
view.) (b) Harvested abductor hallucis myocutaneous free
flap. (c) Prepared bed in a type 2 thenar injury for an
abductor hallucis transfer. The motor branch of the median
nerve has been isolated by intraneural dissection for easy
nerve coaptation proximal to the carpal canal. The ulnar
artery has been isolated at Guyon’s canal for end-to-side
anastomosis to the medial plantar artery. A branch of the
basilic vein has been tagged at the dorsum of the wrist
(arrow), direct anastomosis to the posterior tibial vein will
be possible. (d) Flap inset. (VC, vena comitantes of the
posterior tibial artery; A, medial plantar artery; N; motor
nerve to the abductor hallucis.)
prefer a FFMT. The indication of an abductor hallucis should not be taken lightly
however, any FFMT is more involved than a ‘normal’ free flap, and the muscle tolerance
to ischaemia is lower if function is to be expected from the transfer (Manktelov 1988,
Chuang 1997). Besides this, the abductor is difficult to harvest, and a skin graft has to be
placed on the sole.
In contrast to the abductor hallucis the tendon transfer is a simpler operation,

particularly if it can be combined with a local flap so as not to require microsurgery.
Several tendons can be used as motors: EIP (extensor indicis proprius) to APB (abductor
pollicis brevis) tendon, or FDS IV (flexor digitorum superficialis) to abductor tubercle
using a pulley at the palmar edge of the carpal canal or on a loop at the flexor carpi
ulnaris as recommended by Bunnell being among the most popular (Davis and Barton
1999). If the surgeon decides to use a tendon transfer and there is major loss of soft
tissue, I believe that it should be combined with a free flap rather than a local flap: a free
flap provides the best tissue in the ideal place, with a first class blood supply and the
ability to heal with minimal scarring.
Management of stage 3 is much more complex. The deficient thumb, as in a combined
low median-ulnar nerve palsy, is unable to oppose and lacks strength and stability on side
pinch (plus a massive soft tissue defect). FFMT have been reported to restore the
adductor pollicis (Zhu et al 1985) but the results have been disappointing. Zancolli (1979)
recommends an opposition transfer only if the metacarpophalangeal joint of the thumb is
stable (Zancolli plan 1), and an opponensplasty plus an adductorplasty if the surgeon
wants to provide a strong and more stable thumb (Zancolli plan 2). Again the opposition
can be restored by a FFMT or a tendon transfer.
Stage 4 injury can be managed by pollicization or by adding a toe to the strategy
referred above for stage 3. Pollicization is, in our opinion, the best operation when there
has been damage to the trapezio-metacarpal joint and/or to the index. Pollicization has to
be combined with some kind of flap (a posterior interosseus (Zancolli and Angrigiani
1988, Masquelet 1998) or a free flap) as the soft tissue loss is always extensive
(Binhamer and Lister 1997). Under certain circumstances (young patient, index spared,
work that requires five digits) a toe to hand transfer can be considered, transforming the
situation to a stage 3 (Fig. 5).
Management of severe trauma to the thenar eminence deserves three additional
considerations:
1. Ideally the reconstruction should be done early, in the acute phase. The results are
better then, in our experience, than for the traumatized hand in general (Gupta et al
1999).
2. Major trauma to the thenar eminence is frequently accompanied by silent acute
compartment syndrome involving neighbouring compartments, not directly released
by the injury, that may be responsible for adverse sequelae. The surgeon should be
aware that compartment syndrome of the hand may occur with minimal signs and
symptoms (Piñal et al 2002a). Low threshold to measure the compartmental pressure
is the only way to prevent further damage.
3. Lastly, any major trauma to the thumb inexorably evolves to first web contracture
unless a programme of early serial casting or splints is started soon after the injury.
Established first web contracture unnecessarily complicates the reconstructive plan
and is (nearly) always preventable if the surgeon takes the appropriate measures.
References
Babu V, Chittaranjan S, Abraham G, Korula RJ (1994) Single-stage reconstruction of

soft-tissue defects including the Achilles tendon using the dorsalis pedis arterialized
flap along with the extensor digitorum brevis as bridge graft, Plast Reconstr Surg 93:
1090–4.
Balakrishnan C (1995) Dorsalis pedis flap with vascularized extensor tendons for dorsal
hand reconstruction (letter), Plast Reconstr Surg 95:1335–6.
Banis C (1988) Thin cutaneous flap for intraoral reconstruction: the dorsalis pedis free
flap revisited, Microsurgery 9:132–9.
Bevin AG, Hothem AL (1978) The use of silicone rods under split-thickness skin grafts
for reconstruction of extensor tendon injuries, Hand 10:254–8.
Biemer E, Stock W (1983) Total thumb reconstruction: a one-stage reconstruction using
an osteo-cutaneous forearm flap, Br J Plast Surg 36:52–5.
Binhamer P, Lister G (1997) Pollicization. In: Foucher G, ed. Reconstructive Surgery in
Hand Mutilation. Martin Dunitz: London, 29–39.
Brent B, Upton J, Acland RD et al (1985) Experience with the temporoparietal fascial
free flap, Plast Reconstr Surg 76:177–88.
Caroli A, Adani R, Castagnetti C, Pancaldi G, Squarzina PB (1993) Dorsalis pedis flap
with vascularized extensor tendons for dorsal hand reconstruction, Plast Reconstr Surg
92:1326–30.
Figure 5
(a) Type 4 thenar injury after a combined burn-crush.
Debridement included all thenar and first web muscles.
Only the ulnar hemipulp of the thumb remained viable
(and innervated). Reconstruction was performed 72 hours
later. (b) Intraoperative view highlighting the tendons used
to motorize the first ray: (1) The FDS IV has been
retrieved distal to the carpal ligament and ulnar to the
palmar fascia that will act as the pulley for the
opponensplasty as recommended by Royle–Thompson
(Davis and Barton 1999). A silastic® rod (2) follows the
path of the adductorplasty as recommended by Edgerton–
Omer (modification of Smith transfer: ECRB-third web
space–abductor tubercle) (Omer 1999). The rod will be
used in a second stage to guide a tendon graft and avoid
dangerous dissection around vital nerves and vessels
(artifice suggested by May (1990)). The radial half of the
trapezi-metacarpal joint was lost as was the abductor
pollicis longus (3). The latter will be reconstructed by an
interposition tendon graft. A segment of non-vascularized

humerus restored the dorsal two thirds of the metacarpal.
Arrows point to the proximal stumps of the FPL and EPL
to be sutured to the flexor and extensor hallucis longus
respectively. (c) The thumb has been reconstructed with a
custom made (Foucher et al 1980) trimmed-toe transfer
(Wei et al 1988) in such a way that the innervated ulnar
thumb’s pulp was used to cover the ulnar portion of the
toe. Coverage of the dorsum and the thenar eminence will
be achieved by a split lateral arm free flap (*). Notice that
the silastic® rod has been sutured around the rebuild first
ray metacarpal to provide not only adduction but pronation
(Edgerton in Omer 1999). The tension provided to the
APL and the opponensplasty transfer spontaneously places
the first ray in a physiologic palmar abducted stance. (d)
Result at 6 months. (e) Thumb motion and pinch power at
6 months (the bottle is full).
Cautilli D, Schneider LH (1995) Extensor tendon grafting on the dorsum of the hand in
massive tendon loss, Hand Clin 11:423–9.
Cavanagh S, Pho RWH (1992) The reverse radial forearm flap in the severely injured
hand: an anatomical and clinical study, J Hand Surg 17B:501–3.
Cho BC, Lee JH, Weinzweig N, Baik BS (1998) Use of the free innervated dorsalis pedis
tendocutaneous flap in composite hand reconstruction, Ann Plast Surg 40:268–76.
Cho BC, Byun JS, Baik BS (1999) Dorsalis pedis tendocutaneous delayed arterialized
venous flap in hand reconstruction, Plast Reconstr Surg 104:2138–44.
Chuang DCC (1997) Functioning free-muscle transplantation for the upper extremity,
Cormack GC, Lamberty BG (1994) The ankle and foot. In: Cormack GC, Lamberty BG,
eds. The Arterial Anatomy of Skin Flaps, 2nd edn. Churchill Livingstone: Edinburgh,
258–67.
Davies TRC, Barton NJ (1999) Median nerve palsy. In: Green DP, Hotchkiss RN,
Pederson WC, eds. Green’s Operative Hand Surgery, Vol 2, 4th edn. Churchill
Livingstone: New York, 1497–525.
Desai SS, Chuang DC, Levin LS (1995) Microsurgical reconstruction of the extensor
system, Hand Clin 11:471–82.
Doi K, Muramatsu K, Hattori Y et al (2000) Restoration of prehension with the double
free muscle transfer following complete avulsion of the brachial plexus: indications
and long-term results, J Bone Joint Surg Am 82A:652–66.
Fatah MF, Nancarrow JD, Murray DS (1985) Raising the radial artery forearm flap: the
superficial ulnar artery ‘trap’, Br J Plast Surg 38:394–5.
Foucher G, Merle M (1992) The radial forearm island flap in hand surgery. In: Gilbert A,
Masquelet A, Hentz VR, eds. Pedicle Flaps of the Upper Limb. Martin Dunitz:
London, 89–99.
Foucher G, Merle M, Maneaud M, Michon J (1980) Microsurgical free partial toe
transfer in hand reconstruction: A report of 12 cases, Plast Reconstr Surg 65:616–26.
Foucher G, Van Genechten F, Merle N, Michon J (1984) A compound radial artery

forearm flap in hand surgery: An original modification of the Chinese forearm flap, Br
Gilbert A (1976) Composite tissue transfer from the foot: anatomic basis and surgical
technique. In: Daniller AJ, Strauch B, eds. Symposium on Microsurgery. Mosby: St
Louis, 230–42.
Gupta A, Shatford RA, Wolff TW, Tsai TM, Scheker LR, Levin LS (1999) Treatment of
the severely injured upper extremity, J Bone Joint Surg (Am) 81A: 1628–51.
Harii K, Asato H, Yoshimura K, Sugawara Y, Nakatsuka T, Ueda K (1998) One-stage
transfer of the latissimus dorsi muscle for reanimation of a paralyzed face: a new
alternative, Plast Reconstr Surg 102:941–51.
Hentz VR, Pearl RM (1987) Hand reconstruction following avulsion of all dorsal soft
tissues. A cutaneo-tendinous free tissue transfer, Ann Chir Main 6:31–7.
Hua J, En-tan G, Zheng-lun J, Ming-li J, Van L (1995) One-stage microneurovascular
free abductor hallucis muscle transplantation for reanimation of facial paralysis, Plast
Ibaraki K, Kanaya F (1995) Free vascularized medial plantar flap with functioning
abductor hallucis transfer for reconstruction of thenar defects, Plast Reconstr Surg
95:108–13.
I ik S, Sezgin M, Öztürk S, Selmanpakoğlu N, Kütükçü Y (1997) Free
musculofascicutaneous medial plantar flap for reconstruction of thenar defects, Br J
Ismail TIA (1990) The dorsalis pedis myofascial flap, Plast Reconstr Surg 86:573–6.
Jin YT, Guan WX, Shi TM, Quian YL, Xu LG, Chang TS (1985) Reverse island forearm
fascial flap in hand surgery, Ann Plast Surg 15:340–7.
Katsaros J, Schusterman M, Beppu M et al (1984) The lateral upper arm flap: anatomy
and clinical applications, Ann Plast Surg 12:489–500.
Katsaros J, Tan E, Zoltie N, Barton M, Venkataramakrishnan, Venugopalsrinivasan
(1991) Further experience with the lateral arm free flap, Plast Reconstr Surg 87:902–
10.
Kleinert JM, Fleming SG, Abel CS, Firrell J (1989) Radial and ulnar artery dominance in
normal digits, J Hand Surg (Am) 14A:504–8.
Lee KS, Park SW, Kim HY (1994) Tendocutaneous free flap transfer from the dorsum of
the foot, Microsurgery 15:882–5.
Lin SD, Lai CS, Chiu CC (1984) Venous drainage in the reverse forearm flap, Plast
McCraw JB, Furlow LT Jr (1975) The dorsalis pedis arterialised flap: a clinical study,
Man D, Acland R (1980) The microarterial anatomy of the dorsalis pedis flap and its
clinical applications, Plast Reconstr Surg 65:419–23.
Manktelov RT (1988) Free muscle transfer. In: Green DP, ed. Operative Hand Surgery,
2nd edn. Churchill Livingstone: New York, 1215–44.
Masquelet AC (1998) The posterior interosseous flap in surgery of the hand, Atlas Hand
Clin 3:109–18.
Mathes SJ, Alpert BS (1988) Free skin and composite flaps. In: Green DP, ed. Operative
Hand Surgery. Churchill Livingstone: New York, 1151–213.
May JW Jr (1990) Microvascular great toe to hand transfer for reconstruction of the
amputated thumb. In: McCarthy JG, May JW Jr, Littler JW, eds. Plastic Surgery, Vol
8. WB Saunders: Philadelphia, 5153–85.
May JW, Chait LA, Cohen BE, O’Brien BMc (1977) Free neurovascular flap from the
first web of the foot in hand reconstruction , J Hand Surg 2:387–93.
Mitz V (1986) Second toe to thumb transfer with extensor digitorum brevis
opponensplasty, Ann Plast Surg 17:259–62.
Morrison WA, O’Brien B, MacLeod A (1979) The foot as a donor site in reconstructive
microsurgery, World J Surg 3:43–52.
Nagano A (2001) Intercostal nerve transfer for elbow flexion. Tech Hand Upp Extr Surg
5:136–40.
Nakajima H, Imanishi N, Aiso S, Fujino T (1997) Venous drainage of the radial forearm
and anterior tibial reverse flow flaps: anatomical and radiographic perfusion studies,
Br J Plast Surg 50:389–401.
Omer GE Jr (1999) Ulnar nerve palsy. In Green DP, Hotchkiss RN, Pederson WC, eds.
Green’s Operative Hand Surgery, Vol 2, 4th edn. Churchill Livingstone: New York,
1526–41.
Osaka S, Hoshi M, Sano S, Nozaki M, Yamamoto M (1996) Description of new
composite tissue transfer for salvage of a complex hand defect, Clin Orthop 328:91–3.
Piñal F del, Taylor G (1993) The deep venous system and the reverse flow flaps, Br J
Piñal F del, Herrero F (2000) Extensor digitorum brevis free flap: anatomic study and
further clinical applications, Plast Reconstr Surg 105:1347–56.
Piñal F del, Herrero F, Jado E, Fuente M, García Cabeza JM (2000) Transplantes de dedo
de pie a mano. Análisis de las anomalías arteriales, la disección del pie y la
revascularización, Cir Plast lberlatinamer 26:309–17.
Piñal F del, Herrero F, Jado E, García-Bernal JF, Cerezal L (2002a) Acute hand
compartment syndromes after closed crush: a reappraisal, Plast Reconstr Surg 110:
1232–9.
Piñal F del, Herrero F, Jado E, Oteo JA, García-Bernal JF (2002b) Salvage and functional
rehabilitation of a massively crushed hand with two sequential free flaps. Case report,
J Trauma 53:980–3.
Quaba AA, Elliot D, Sommerlad BC (1988) Long term hand function without long finger
extensors: a clinical study, J Hand Surg (Br) 13B:66–71.
Reid CD, Moss ALH (1983) One-stage flap repair with vascularized tendon grafts in a
dorsal hand injury using the ‘Chinese’ forearm flap, Br J Plast Surg 36:473–9.
Samson MC, Morris SF, Tweed AEJ (1998) Dorsalis pedis flap donor site: acceptable or
not? Plast Reconstr Surg 102:1549–59.
Scheker LR, Kleinert HE, Hanel DP (1987) Lateral arm composite tissue transfer for
ipsilateral hand defects, J Hand Surg (Am) 12A:665–72.
Scheker LR, Langley SJ, Martin DL, Julliard KN (1993) Primary extensor tendon
reconstruction in dorsal hand defects requiring free flaps, J Hand Surg (Br) 18B: 568–
75.
Shen Z (1989) Vascularized tendon grafting from the dorsum of the foot: a functional
anatomic study and clinical experience (abstract), J Reconstr Microsurg 5:90.
Singer DI, Morrison WA, Gumley GJ et al (1989) Comparative study of vascularized and
nonvascularized tendon grafts for reconstruction of flexor tendons in zone 2: an
experimental study in primates, J Hand Surg (Am) 14A:55–63.
Smith RA (1980) The free fascial scalp flap, Plast Reconstr Surg 66:204–9.
Song R, Gao Y, Song Y, Yu Y, Song Y (1982) The forearm flap, Clin Plast Surg 9:21–6.
Song YG, Chen GZ, Song YL (1984) The free thigh flap: a new free flap concept based
on the septocutaneous artery, Br J Plast Surg 37:149–59.
Sundine M, Scheker LR (1996) A comparison of immediate and staged reconstruction of
the dorsum of the hand, J Hand Surg (Br) 21B:216–21.
Tamai S, Sakamoto H (1993) Free sensory skin flap transfers to the hand. In: Tubiana R,
ed. The Hand, Vol 4. WB Saunders: Philadelphia, 795–810.
Tamai S, Fukui A, Shimizu T, Yamaguchi T (1983) Thumb reconstruction with an iliac
bone graft and a dorsalis pedis flap transplant including the extensor digitorum brevis
muscle for restoring opposition: A case report, Microsurgery 4:81–6.
Tamai S, Yajima H, Inada Y (1999) Secondary reconstruction of the extensor tendons
and overlying soft tissue deficiency, Hand Clin 15:555–61.
study and clinical technique, Br J Plast Surg 32:170–83.
Taylor GI, Palmer JH (1987) The vascular territories (angiosomes) of the body:
experimental study and clinical applications, Br J Plast Surg 40:113–41.
Terzis JK, Mersa B (2001) Facial reanimation. In: Goldwyn RM, Cohen MN, eds: The
Unfavourable Result in Plastic Surgery. Avoidance and Treatment. Lippincott
Williams & Wilkins: Philadelphia, 597–610.
Upton J (1998) Direct visualization of arterial anatomy during toe harvest dissections:
clinical and radiological correlations, Plast Reconstr Surg 102:1988–92.
Vila-Rovira R, Ferreira BJ, Guinot A (1985) Transfer of vascularized extensor tendons
from the foot to the hand with a dorsalis pedis, Plast Reconstr Surg 76:421–7.
Wei FC, Chen HC, Chuang CC, Noordhoff MS (1988) Reconstruction of the thumb with
a trimmed-toe transfer technique, Plast Reconstr Surg 82:506–13. Wei FC, Jain V,
Celik N, Chen HC, Chuang DCC, Lin HC (2002) Have we found an ideal soft tissue
flap? Experience with 672 anterolateral thigh flaps, Plast Reconstr Surg 109:2219–26.
Yajima H, Inada Y, Shono M, Tamai S (1996) Radial forearm flap with vascularized
tendons for hand reconstruction, Plast Reconstr Surg 98:328–33.
Yousif NJ, Warren R, Matloub HS, Sanger JR (1990) The lateral arm fascial free flap: its
anatomy and use in reconstruction, Plast Reconstr Surg 86:1138–45.
Zancolli E (1979) Intrinsic paralysis of the ulnar and median nerves. In: Zancolli EA, ed
Structural and Dynamic Bases of Hand Surgery. Lippincott: Philadelphia, 207–28.
Zancolli EA, Angrigiani C (1988) Posterior interosseous island forearm flap, J Hand
Surg (Br) 13B:130–5.
Zhou G, Qiao Q, Chen GY, Ling YC, Swift R (1991) Clinical experience and surgical
anatomy of 32 free anterolateral thigh flap transplantations, Br J Plast Surg 44:91–6.
Zhu SX, Zhang BX, Yao JX, Li ZY, Wang XL, Fu ZG (1985) Free musculocutaneous
flap transfer of extensor digitorum brevis muscle by microvascular anastomosis for
restoration of function of thenar and adductor pollicis muscles, Ann Plast Surg
15:481–8.
General indications
21
Principles of emergency reconstruction
Abel Nascimento
Introduction
During the past 25 years, there has been a major advance in plastic reconstruction of the
limbs. However, we cannot ignore the pioneering studies of Manchot (1883–88) and
Salmon (1933–36) on human cutaneous vascularization (Manchot 1983, Salmon 1936).
Gillies, in spite of his vast amount of work in reconstructive surgery during and after the
second world war, did not achieve the expected results since he was unaware of the
studies of Manchot and Salmon (Gillies and Millard 1957). It was only in the late 1970s
and in the early 1980s, that knowledge of the anatomical details of limb vascularization
(bone, muscle and skin) nerve cartography and flap standardization increased
tremendously. The concepts of septal and subfascial vascularization, as well as direct and
inverted flow flap vascularization (haemodynamic concept), were described at this time
(Ponten 1981). Simultaneously, there have been major developments in experimental
animal surgery, leading to a considerable increase in knowledge and the experience of
general concepts of microsurgical techniques. The author has been involved in the study
and standardization of several flaps (1982–83), performing research in more than 200
fresh cadavers in Paris (Nascimento 1983a, b, 1984, 1994).
After an initial experimental phase of free flap application, standardization has been
achieved of well defined plastic reconstructive techniques, using, whenever possible,
pediculated vicinity flaps, both direct and inverted flow.
Although it is a basic concept, the importance of high standards of planning and
experience of the surgeon in emergency is emphasized. The hand surgeon’s knowledge
should cover several surgical disciplines to obtain good results. In our opinion, they must
have ‘the five fingers knowledge’ to perform hand surgery: anatomy, orthopaedics and
plastic, vascular and nerve surgery.
We do not advocate multidisciplinary teams to perform reconstructive surgery of the
limbs. A team of hand surgeons should treat complex upper limb trauma. This team
should be organized to ensure an emergency service roundthe-clock (SOS Hand
University Hospital of Coimbra and Institute of Reconstructive Surgery).
The treatment of complex trauma in emergency should be preceded by stabilization of
vital signs with general cardiorespiratory, haemodynamic and neurologic balance. Only
after a general evaluation of the trauma (cranial, thoracic and abdominal), stabilization
and treatment planning can we consider the treatment of the limbs. It is obvious that, at
Principles of emergency reconstruction 353
the first opportunity, the limbs should be daced in the correct axial orientation. Vascular
and nerve injuries should be evaluated in order to attain haemodynamic stability and
protected from incurring further damage from bony splinters. Evaluation of a limb from
the perspective of reconstruction is extremely important, since one should only
reconstruct a limb segment in which necrosis and infections are not anticipated. As
function is the ‘primum movens’ of reconstruction, the latter without a functional purpose
ought to be carefully considered. Single surgical procedures, even though of great extent,
should not be implemented without a strict, serious and very well defined protocol in
order to recover function. Cost-benefit analysis, age, profession of the patient, etc. are
important factors to consider when planning the most convenient surgical procedure to
reconstruct a severely traumatized upper limb. The principle ‘primum non nocera’ should
always be present in the mind of the surgeon. The vast array of surgical techniques at
their disposal should not obscure good and practical clinical sense (Nascimento 1989).
The strategy for emergency reconstruction of upper limb bone, muscles, vessels,
nerves and skin must envisage these structures as a whole. This is a very important
postulate, since reconstruction of one of these cannot be considered individually, if our
goal is to obtain a good anatomical, aesthetic and functional recovery. The main
principles for the reconstruction of these structures are now discussed.
Bone
Bone reconstruction, in an avulsion injury or linear amputation, should follow general

orthopaedic principles. The osteosynthesis should be performed using stabilization with a
diaphyseal, metaphyseal intramedullary nail or fragmentary compression type plate low
contact-distraction compression plate (LC-DCP). In joint trauma, if osteosynthesis for
functional recovery is not possible, arthrodesis (shoulder, elbow, wrist) or replacement
with a prosthesis should be considered. One of the essential rules for all avulsion injuries,
due to risk of infection, is to perform debridement of dead tissue, together with thorough
washing under pressure and scrubbing (including the bone), since preserving
nonvascularized fragments is extremely dangerous. Bone shortening is of vital
importance for the success of the surgery. One should not hesitate to shorten the bone
several centimetres; besides providing a stable osteosynthesis it will avoid prolonged
surgery for the repair of the other structures. We have defended this principle in several
international meetings and demonstrated this to be one of the most important factors
contributing to the success of macroreimplantations and sphacelus reconstruction
(Nascimento 1994).
The shortening of the bone should be done to enable direct suturing of vascular and
nerve structures (whenever possible); musculo-tendinous anatomical reconstruction
without gaps; fasciocutaneous sutures without tension; vascularization of the structures
without deficit; and also to avoid the use of covering flaps. It is better to have a short
functional limb than one with normal length but presenting nerve, vascular and functional
abnormalities. Later on, if necessary, the reconstructed limb can be elongated using one
of the several methods of bone distraction.
There are cases of sphacelus/tearing away of the entire upper limb, with only the
uncovered humerus remaining. Glenohumeral or even omothoracic disarticulation should
be avoided, preserving the glenohumeral joint, either by osteosynthesis or by arthrodesis

and a myofasciocutaneous flap (usually with the latissimus dorsi) (Fig. 1).
Muscles
In a muscular sphacelus of the upper limb we should bear in mind several extremely
important principles of surgical evaluation and planning in emergency. Muscle is a tissue
that easily becomes necrotic and oedematous. Its fibres remain highly contracted and
retracted and have a poor regenerative power. If the injury reaches the neuromotor plates
there will be a high probability of decrease/loss of function. Nevertheless, muscles are
very useful as local pediculated flaps or as free flaps for plastic reconstruction of soft
tissue loss. The time to treatment of a
Figure 1
(a) Avulsion of the upper limb. Plastic reconstruction with
a pediculated latissimus dorsi flap. (b) Eight days after
surgery.
sphacelus with major muscular involvement is short, due to the irreversible

necrosis/metabolic acidosis of the destroyed or avascular muscular mass. The urgency of
the repair increases as we go from the distal to the proximal portion of the upper
extremity—in some situations, a distal sphacelus/amputation could wait for several hours,
while a proximal one should be treated within 2–3 hours.
We should always bear in mind, that repair of a proximal sphacelus/amputation with
revascularization can be life threatening for the patient (the so-called revascularization
syndrome, shock kidney and lung). In a forearm and arm reconstruction, the arterial part
should always be done first, leaving the vein to drain freely to preclude the precipitation
of the above mentioned syndrome (myoglobinuria).
One of the major complications in major trauma of the forearm and the arm is the
compartment syndrome. This syndrome may occur even in fractures without major
injuries to other structures. Basically it starts as a haematoma of the arm, forearm (higher
incidence) and hand compartments, which compromise muscle, nerve and vessel
viability. It is an emergency situation which should be constantly monitored and requires
decompressive fasciectomies, in order to protect the vitality of the limb and to avoid later
complications (Volkmann’s contracture).
In this context, in major sphacelus/amputations we perform an elementarectomy (Fig.
2) (Brunelli et al 1985). Every devitalized muscle as well as all the muscles and tendons
that can be discard should be removed, enabling survival of the structures inside the
fasciocutaneous involucre without compression from the oedema that occurs
immediately. This oedema starts to decrease by the fifteenth day post surgery. This
procedure is of great importance in major sphacelus/amputations, as it will avoid vascular
compression in regard to the superficial venous drainage. This same procedure justifies
the success of our macroreimplantations compared with international series. In forearm
sphacelus/ amputations, superficial muscles and flexor tendons, as well as some muscles
distal to their innervation and vascularization are discarded to achieve this aim. As we
will refer to later in reconstruction by regions, the upper limb, thorax and scapular girdle
muscles are very important for reconstruction, preservation and motorization in the
surgical emergency protocol.
Vessels
A reconstructive surgeon should have very detailed knowledge of the arterial, venous and
lymphatic networks, both macro- and microcirculation, to be able to plan the ideal
treatment protocol in emergency for major trauma of the upper limb. Macro- and
microvascular techniques should be routine for this surgeon. As we already mentioned,
we should perform, as much as possible, an end-to-end reconstruction in sphacelus/
amputation situations, even if we have to shorten a bone by several centimetres. Vascular
grafts are used in lesser injuries with skeletal integrity. Bones, tendons and muscles
should be the first structures to be repaired to achieve a stable vascular suture. In a
brachial plexus injury with a proximal lesion of the subclavicular or axillary arteries or in
presence of an omothoracic high energy distension, there is a rule which is rarely
followed: reconstruction with a saphenous vascular graft of the arteries should be used as
a bypass to avoid the anatomical field of the brachial plexus, so that it can subsequently
be repaired free of fibrotic involvement. In our opinion this vascular reconstruction
should be
Figure 2
(a) Complete amputation/sphacelus of the right forearm.
Shortening of the bones and reconstruction of all structures
with gracilis muscle transfer post-elementarectomy. (b)
Flexion 1 year after surgery.
done by the hand surgeon/microsurgeon and not by the vascular surgeon to provide the
best brachial plexus recovery.
As it is well known, there are two concomitant veins for each artery, besides the
superficial fasciocutaneous veins. We emphasize the importance of the reconstruction of
the concomitant veins for the success of a great sphacelus/reimplantation, even if one or
two superficial veins of considerable calibre are reconstructed.
Our extensive animal experimental work on amputation/reimplantation of dog’s hind
limb (more than 100)—to study oedema formation and tissue regeneration, specially of
lymphatic vessels—enhanced our knowledge and supports these axioms (Nascimento
1983b, 1987, 1994). That is why we insist that reconstruction of deep vascular axes
accounts for success of major reconstruction/reimplantation. Well functioning veins, in
the first days after reconstruction, can occlude due to decrease in speed of flow and
reduction in calibre by compression from the acute oedema and hypertension.
Lymphatic vessels are extremely significant in post-traumatic resolution of oedema of
the upper limb. The lymphatic network, although of great importance, is almost unknown
to the great majority of surgeons. Around 10 years ago, we performed thorough research
(Nascimento 1994)—using experimental animal surgery and injection/dissection of fresh
cadavers—to study the role of capillaries, small and great lymphatic vessels in limb
injuries, namely sphacelus, amputations and fasciocutaneous flaps. We will not describe
the results of these investigations in detail, but we will refer to some of the conclusions
that might be useful to understand the different phases of oedema.
Following an injury/trauma, the body releases different kinds of cells (macrophages,
lymphocytes, platelets, etc.). These cells release chemotactic and growth factors to
initiate immediate tissue regeneration. Following use of histochemical-enzymatic
methods for optical microscopy, scanning microscopy, anatomical microsurgical
dissection, gelatine/China ink, epoxy resin/corrosion and barium sulphate selective
injection, digital arterio- and venography, direct and indirect lymphography and direct
and indirect lymphoscintigraphy in dog’s hind limb amputation/reimplantation as well as
after applying some of these methodologies to fresh cadavers and clinical cases of total
limb reimplantations and flaps we reached the following conclusions. (1) Muscle, arterial,
venous and lymphatic capillaries start regenerating immediately; (2) blood vessel
reorganization begins around the third day; (3) on the seventh day there is a true
reorganization/regeneration of the venous system, which markedly contributes to
drainage of oedema; (4) lymphatic capillaries and afferents remain open below and above
the lesion, draining the lymph to the interface; (5) only lymphatic capillaries and very
small afferents can regenerate; (6) in the connective tissue of the drainage area a
connection is established between the distal and proximal lymphatic afferents (lymphatic
lakes); (7) as is well known, the lymphatic system removes macromolecules (>40 KDa),
cleansing the interstitium distal to the wound. Although there is no regeneration of the
great lymphatics, they play an important role in acute and subacute drainage of oedema in
a sphacelus/reimplantation/flap. We also concluded that the venous system regenerates
around the seventh day and plays an active part in the initial hypertension phase of
posttraumatic acute oedema. Nevertheless the lymphatics, in a passive way, help the
drainage of the fluid as they remain open for a while. A gentle massage during the initial
phase helps to drain the interstitial fluids, mainly macromolecular components of the
fluids. An intempestive massage is not advised, since it destroys the tissue regenerative
linkage of all structures, mainly lymphatic. High doses of heparin enhance draining of the
system.
Our studies confirmed the doubtful existence of venolymphatic communications due

to high pressure. Following selective injection of different coloured resins (experimental
study) into the venous and lymphatic systems we observed mixing of colours at certain
points. We proved, for the first time, that both systems communicate regularly at
capillary and lymph node levels (Nascimento 1994). This is due to the intricacy of both
the venous and the lymphatic system, sharing the same embryologic origin. Thus, based
upon well defined and structured scientific data, we can conclude that in spite of suturing
one, two or three veins in a sphacelus/amputation, without reconstruction of lymphatic
afferents, the oedema disappears in the second and
Figure 3
(a) Arteriography at 10 days. (b) Venography at 10 days.
(c) Lymphography at 20 days.
third weeks, as the venous and lymphatic drainage occurs all around the interface.
The same principle applies to flaps, even random ones, 3 weeks after surgery. This
knowledge also leads us to recommend bone shortening in a sphacelus/amputation;
anatomical positioning and suture of all structures; deep suture of vascular trunks to
juxtapose lymphatic afferents enhancing drainage and muscle fibroconnection to improve
its poor regeneration (Fig. 3).
Nerves
Besides the already referred to purposes, shortening of structures enables an end-to-end

nerve suture without tension, which is vital for motor and sensory recovery of the injured
limb. Any tense nerve suture will cause a neuroma. Nerve sutures should always be done
in emergency whenever there is a linear cut and an epiperineural suture is possible
without tension. Sometimes it is necessary to dissect, both distally and proximally, the
nerve (obviously without destroying its vascularization) to achieve a good suture. When
there is nerve tissue loss larger than 1–2 cm, it will not be possible to do a suture without
tension, even after performing nerve dissection; we will then use a graft in scheduled
surgery. Nevertheless, following the above guidelines we obtained almost total nerve
recovery (even in reimplantations). Using nerve grafts will not lead to as good results as
direct sutures in emergency. We emphasize that, when necessary, it is better to do bone
shortening and a direct suture than to use a graft in scheduled surgery. Another great
negative factor of secondary nerve reconstruction is that a second approach/dissection

will destroy the reorganization of blood and lymphatic vessels. In addition, when there
are large nerve injuries in sphacelus/amputation at the elbow and arm levels associated
with complete brachial injury, indications for limb preservation are reduced or absent.
Skin
Cutaneous coverage of tissue loss in upper limb trauma is one of the most demanding and
satisfying procedures for the hand surgeon. The surgeon must be familiar with all the
techniques necessary to perform simple and composite, pedicled direct and indirect flow,
septal and free flaps (Mathes and Nahai 1979, 1981, 1982, Cormack and Lamberty
1984a,b, 1987, Foucher et al 1984, Nascimento 1984, 1994, Cormack et al 1986,
Masquelet and Penteado 1987; Costa and Soutar 1988; Gilbert et al 1990).
Principles of plastic reconstruction by regions

Shoulder: Depending on the structures injured, the shoulder can be reconstructed using
pedicled flaps: latissimus dorsi (myofasciocutaneous) flap, pectoralis major flap,
proximal pedicled lateral external flap of the arm, brachial internal flap and free flap
(following the preference and experience of the surgeon).
Arm: Latissimus dorsi (myofasciocutaneous) flap, lateral external flap of the arm,
brachial internal flap (function of the injured area), free flap.
Elbow: Latissimus dorsi flap, lateral external flap of the arm, proximal flow
antebrachial radial flap (Chinese), brachio radialis flap, carpi ulnaris flexor flap, proximal
flow interosseous dorsal flap, free flap.
Forearm: Distal pedicled lateral external flap of the arm, interosseous dorsal flap,
antebrachial radial flap, antebrachial cubital flap (as a last choice), McGregor flap,
accessory cubital flap (Becker’s), free flap (Figs 4–8).
Figure 4
(a) Seen in emergency 5 days after an accident with a
sphacelus of the distal forearm and wrist, without
vascularization of the hand. Thrombosis of the radial and
ulnar arteries with infection. Escharectomy (skin, nerves,
tendons, vessels), reconstructionusing vessel grafts and
tendon spacers and plastic reconstruction with a free flap
(lateral forearm flap) in emergency. (b) Perioperative view
showing tendon spacers. (c) Free flap application (lateral
forearm flap).
Wrist, back of the hand and palmar area: Coverage of the back of the hand and of the
palmar area are planned separately, due to the different composition of the skin.
The dorsal face of the hand can receive a simple skin graft when the epitenon is
preserved. Nevertheless, reverse flow pediculate flaps such as the interosseous dorsal, the
antebrachial radial (Chinese), Becker’s flap, the flap based upon the arteries of the
intermetacarpal spaces, the pediculated McGregor’s flap and free flaps are the best
options for reconstruction of the dorsal aspect of the hand, according to the experience of
the surgeon and the type
Figure 5
(a) Forearm cutaneous sphacelus caused by a shot gun:
flexor digitorum profundus destruction with partial finger
extensor digitorum communis. Gracilis muscle transfer for
digital motorization/flexion with tendon transfer at the
extensor level. (b) Post-surgical motor function
(extension). (c) Post-surgical motor function (flexion).
Figure 6
(a) Sphacelus of the wrist and dorsal aspect of hand, with
avulsion of the proximal insertion of extensor tendon.
Complete destruction of the carpal bones and metacarpal
and phalangeal fractures. Cubital and radial arteries and
median and ulnar nerve lesions. Forearm bone fractures
and circumferential trauma of the soft tissues. (b)
Radiological image. (c) Reconstruction of all the structures
(tendons, arteries, veins, nerves) with arthodesis of the
wrist and McGregor flap: post-surgical function.
Figure 7
(a) Traumatic sphacelus/amputation at elbow and proximal
forearm levels in a train accident. (b) Shortening (several
cm) of the upper limb and arthrodesis of the elbow. Artery
and vein reconstruction with grafts, elementarectomy.
Biceps and brachialis muscle transfer for flexor digitorum
profundus; brachioradialis muscle transfer for extensor
pollicis longus; triceps muscle (three fascicles) for the
extensor tendons. Flexor carpi radialis and flexor carpi
ulnaris tenodesis along with extensor carpi radialis brevis
and extensor carpi radialis longus tenodesis. Median, ulnar
and superficial radial nerves reconstruction.
Figure 8
(a) Post-surgical function 1 year and 6 months later (same
case as in Fig. 7). Thenar and hypothenar recovery.
Extension of the digits. (b) Active finger flexion.
of injury. In bone, tendon and skin injuries of the back of the hand it is possible to plan an
anatomical reconstruction of all the structures at the same time, either using bone grafts
followed by coverage with tendinofasciocutaneous composite flaps (Chinese flap) or
leaving tendons spacers for subsequent reconstruction (Fig. 9).
Figure 9
(a) Soft tissue and bone sphacelus of the wrist and dorsal
aspect of the hand, with oil injection into the bones.
Reconstruction of the bones and a composite. Chinese flap
with tendons. (b) Post-surgical flexion.
Figure 10
(a) Avulsion of the palmar skin of the hand and
reconstruction with the Chinese flap in emergency. (b)
Result after aesthetic lipotomy.
The palmar region requires reconstruction with a fasciocutaneous flap. A free skin
graft can never be used due to the texture and mechanical demands of the area during
daily and professional activity (Fig. 10). We can use the antebrachial radial flap with
deep sutures and subsequent aesthetic lipotomy, McGregor’s flap as a last choice and free
flaps, from which we suggest the internal plantar flap (with similar texture). Obviously, a
bone and tendon reconstruction can be done in one or two operations to re-establish
motor function of the hand.
One of the most challenging and satisfying areas, accounting for a great number of
cases, is probably the reconstruction in emergency of a finger’s amputation stumps—
using ‘bank fingers’ with the associated flap, fourth contralateral hand finger transfer,
toe-to-hand finger transfer for thumb reconstruction, fasciocutaneous pediculated digital
flaps—whose multiplicity only ends where the surgeons’s imagination stops. This is a
very interesting subject but it was not included in this chapter.
References
Brunelli G, Vigasio A, Brunelli F (1985) L’elementarisation musculaire dans les

reimplantations et les revascularisations. ‘Limite’ de l’avant-bras, Ann Chir Main
4:337–9.
Cormack GC, Lamberty BGH (1984a) A classification of fasciocutaneous flap according
to their patterns of vascularization, Br J Plast Surg 37:80–7.
Cormack GC, Lamberty BGH (1984b) Fasciocutaneous vessels in the upper arm:
application the design of new fasciocutaneous flaps, Plast Reconstr Surg 74:244–9.
Cormack GC, Lamberty BGH (1987) The Arterial Anatomy of Skin Flaps. Churchill
Livingstone: New York.
Cormack GC, Duncan MJ, Lamberty BGH (1986) The blood supply to the bone
component of the compound osteo-fasciocutaneous radial artery forearm flap, Br J
Costa H, Soutar DS (1988) The distally based island posterior interosseous flap, Br J
Foucher G, Gilbert A, Merle M, Jacob Y (1984) Lambeau radial ‘chinois’. In: Tubiana R,
ed. Traité de Chirurgie de la Main, vol II. Masson: Paris, 244–9.
Gilbert A, Masquelet AC, Hentz RV (1990) Les Lambeaux Artériels Pédiculés du
Membre Supérieur. Expansion Scientifique Française: Paris:17.
Gillies H, Millard DR (1957) The Principles and Art of Plastic Surgery. Little Brown &
Co: Boston.
Manchot C (1983) The Cutaneous Arteries of the Human Body. (Translation of Die
handarterien des menschlichen Körpers (1889)). Springer-Verlag: New York.
Masquelet AC, Penteado CV (1987) Le lambeau interosseux postérieur. Ann Chir Main
6:131–9.
Mathes SJ, Nahai F (1979) Clinical Atlas of Muscle and Musculocutaneous Flaps. CV
Mosby: St Louis.
Mathes SJ, Nahai F (1981) Classification of the vascular anatomy of muscles:
experimental and clinical correlation, Plast Reconstr Surg 67:177–87.
Mathes SJ, Nahai F (1982) Clinical Application for Muscle and Musculocutaneous Flaps.
CV Mosby: St Louis.
Nascimento A (1983a) Anatomie Chirurgicale des Muscles Jumeaux et Vascularization
de la Peau du Mollet. Mémoire d’Assistant Etranger de la Faculté de Médecine René
Descartes: Université de Paris, Paris.
Nascimento A (1983b) Homotransplant du Genou Vascularisé du Rat. Mémoire
présentée au Laboratoire de Chirurgie Expérimentale de Paris (‘Fer-à-Moulin’).
Nascimento A (1984) Etude anatomo-chirurgicale d’un nouveau lambeau sensible: le
lambeau externe du bras. Société d’Anatomie de Paris, Musée Orfila, March 2.
Nascimento A (1987) Transplante vascularizado do joelho do rato com e sem
ciclosporina A, Rev Ortop Traum 1B:56–62.
Nascimento A (1989) Reconstructive microsurgical techniques in the upper limb. In:
Carolli A, Zanassi S, eds. Proceedings of the 1st European Congress of Hand Surgery.
Modenna: Italy, 180–3.
Nascimento A (1994) Reconstruction plastique du membre supérieur—Investigation

anatomique et application chirurgicale et régénération lymphatique en
réimplantations et lambeaux vascularisés dans la chirurgie expérimentale et clinique.
European PhD Thesis, UFR Biomédicale Saints-Pères, Université René Descartes,
Paris V.
Ponten B (1981) The fascio-cutaneous flap, its use in soft tissue defects of the lower leg,
Br J Plast Surg 34: 215–20.
Salmon M (1936) Les Artères de la Peau. Masson et Cie: Paris.
22
Principles of repair of a compound defect
as a secondary procedure: the multiple
stages approach
Alain C Masquelet
A secondary procedure implies that a compound injury is not recent and that the
treatment is not performed in emergency. Most of time, the treatment of a complex injury
of the upper limb in emergency is based on the principle of repairing all the injuries in a
‘one-stage procedure’ (Michon et al 1977, Lister and Schecker 1988). When the injury is
treated secondarily one should be prepared for complications or adverse sequelae and the
‘one-stage procedure’ cannot be applied safely, especially when the defect involves
several structures. The repair of a compound defect comes under the field of
reconstructive surgery. Obviously, a compound defect involves several kinds of tissue but
the final goal of the treatment is not necessarily to restore all structures in their entirety.
The goal of treatment is to restore function of the upper limb to an acceptable level
compatible with the initial lesions and the possibilities provided by reconstructive
surgery. A compound defect of the upper limb requires an holistic view of the
musculoskeletal system. This system can be defined according to anatomical regions,
functional entities or types of tissues. From these different points of view, the upper limb
comprises the shoulder girdle, the arm, the elbow, the forearm, the wrist and the hand.
The primary aim of the upper limb is to support the function of prehension which
involves the positioning of the hand in space. The upper limb is made of several kinds of
tissue including skin and adipo-fascial tissue, muscles and tendons units, bones and
joints, and nerves and vessels.
A compound defect involves at least two differents kind of tissue (or more) and any
combination is possible. There are four important points for a reconstructive surgeon to
reflect upon:
1. Assess the lesions and define the final goal of the treatment.
2. Decide a general strategy.
3. Determine tactics.
4. Choose the surgical techniques.
Assess the lesions and define the final goal of the treatment
The assessment should consider the function and the defect of the particular tissues which
contribute to the functional impairment. Obviously, the status of the impairment and the
extent of injuries influence the final goal of the treatment. Ideally the aim of the treatment
is the ‘restitutio ad integrum’ of the function of the upper limb and hand.
However, in several cases, the initial impairment is so severe and the possibilities so
limited that the aim of the treatment can only be to improve the function, or to provide
palliative function. This means that the first step (assessment and goal of the treatment) is
the most important one, since it requires vast experience to determine what one can hope
from the treatment. A much too ambitious goal may lead to complete failure and to a
final prejudiciable result.
A good example of compound sequelae is the Volkmann syndrome which is defined
as the final and definitive evolution of a non-treated compartment syndrome.
The function of the hand should be assessed as well as the function of the whole upper
limb. Then each component should be assessed and the evaluation of each tissue can be
done starting from the skin surface to the depth of the bone:
1. Skin envelope: note the presence of defects, skin grafts, contractures, scars; etc.
2. Muscles: evaluate the degree of atrophy or fibrous transformation.
3. Tendons: assess the importance of destruction or adherences.
4. Nerves: are there disturbances in sensory function or paralysis? Can some nerves be
used for neurotization?
5. Joints: assess stiffness, active and passive motions.
6. Bone: is there malunion, non-union, bone defects?
One of the most important issues is the presence or absence of an infection involving the
bone and soft tissues.
The assessment may require examinations like MRI (magnetic resonance imaging) to
evaluate muscle dystrophy, standard radiographs and bone scans for the bone,
arthrograms to evaluate the chondral surface of the joints, arteriograms for the arterial
network, echo Doppler for the veins and EMG (electromyography) or evoked potentials
for evaluation of nerve and muscle functions.
After the assessment of the lesions the final goal of the treatment is defined. Will it be
possible to restore all the functions or is it better to restore one particular function that
will be useful for the patient? For example, in some cases of Volkmann syndrome the
muscle lesions are so important and definitive that it is preferred to restore a key pinch
than to restore a true opposition of the first column.
The general strategy of reconstructive surgery
The general strategy of reconstructive surgery is defined by what we have called the three
Rs.
• Repair of the soft tissue envelope.
• Reconstruction of bone and joints.
• Restoration of function.
Reconstructive surgery is devoted to the restoration of living structures and involves a
high degree of specificity, which can be understood when we compare reconstructive
surgery to ship-building. There is a great difference between these two activities. Ship-
Principles or repair of a compound defect as a secondary procedure 367
building begins at the keel, ribs and floor frame which can be compared to the bony
skeleton; the keel is often compared to the spine. The second step of ship-building is
planking which is the equivalent of the skin envelope of the human body. Finally, the
construction of the mess and decks is like the restoration of function. The difference is
that for building a ship we are obliged to begin from the ‘skeleton’ while in
reconstructive surgery nothing can be undertaken without restoring the skin envelope.
Thus, I do believe that, when faced with a compound defect, we should begin by
repairing the soft tissue envelope. Then the reconstruction of the bones and joint system
will be possible and finally, a healthy envelope, a healed skeleton and mobile joints allow
the restoration of function; that means to restore active motion.
The presence of an infection is an indication for large debridement and a radical
excision of all infected tissues prior to the repair of the envelope and the bone.
Tactics
Tactics can be defined as the different combinations in timing of the three components of
the strategy:
• Repair of the soft tissue envelope.
• Reconstruction of bone and joints.
• Restoration of function.
Generally speaking, if each step of reconstructive surgery is performed separately it
requires a simple palliative procedure.
When treating a compound defect it is possible to begin by repairing the soft tissue
envelope: then in a second procedure the bone and joint are reconstructed. The restoration
of active function is undertaken in a third step (see Case 1 below).
However, we may perform the repair of the soft tissue and the reconstruction of bone
in a one-stage procedure. For example, we may perform, in the same operative procedure,
a conventional bone graft to restore the continuity of a bone and a fascio-cutaneous flap
to repair the envelope. In other cases a compound flap may be used. Scapula and
latissimus dorsi, fibula and soleus muscle, iliac crest and groin flaps allow the
reconstruction of a compound defect in a one-stage procedure. The restoration of function
will be done when bone is healed and the soft tissues repaired.
In some cases, the compound defect may involve only skin and tendons without the
bone, and we can use a compound skin and tendon transfer. So the tactical possibilities
allow us to
Figure 1
The defect involved the skin envelope, the radius and the
extensor tendons of the wrist and fingers. Radial artery
was avulsed but the hand was well vascularized by the
ulnar artery. The median nerve was intact.
decide whether to perform the reconstructive surgery in one, two or three stages
according to the clinical requirements. It should be understood that to decide on the
tactics a precise assessment of the defect and knowledge of all the technical possibilities
is required.
Case 1 (Figures 1–5)

This is a case of gun-shot injury in a 25-year-old man. Treatment in emergency
comprised of debridement and bone fixation. The patient was transferred 3 weeks later
with an infected wound.
Figure 2
The first stage after radical excision consisted of the soft
tissue repair by a free serratus anterior muscle flap. A
cement spacer was placed in the bone defect.
Figure 3
(a) Two months later, the cement spacer was removed and
the radius was reconstructed by autologous fresh
cancellous bone graft. (b) The external device was
replaced by a plate 2 months later. Bone healing was
complete at 4 months.
Surgical techniques
The choice of the surgical technique is the last step in the surgeon’s reflection of a
compound defect. It depends on the importance and the nature of the defect and the
tactics chosen. Reciprocally, the surgical procedures available determine the tactics.
Advances in techniques also influence the tactics. The techniques comprise all the
procedures to reconstruct the injured tissues in a compound defect of the musculoskeleton
system: skin envelope repair, bone and joint reconstruction and restoration of function.
All procedures range on a ladder from the most simple (which is also the easiest
procedure) to the most sophisticated (which is, most often, the most technically
demanding procedure).
The repair of the soft tissue envelope

The procedures to repair the soft tissue envelope are as follows: spontaneous healing,
plasties, vacuum-assisted closure, skin expansion, skin graft, local flap, island pedicled
flap, free flap, etc. Obviously, the procedure that will be employed depends on the size of
the defect, the local conditions and the time of reconstruction.
Figure 4
The restoration of the function required two stages. (a) In a
first stage silicone rods were placed beneath the flap. (b) In
a second stage, the continuity of the extensors of the wrist
was restored by a fascia lata graft (flexor carpi ulnaris).
Finger extension was restored at the same time by a
transfer of the FCU tendon.
Figure 5
(a,b) Clinical result.
For example, skin expansion is not advocated in an emergency, but it is suitable when
there is a retractile scar. In our opinion, when a flap is required, the tendency should be to
use a pedicle flap as far as possible since it is a more reliable and quicker procedure than
a free flap.
Bone and joint system reconstruction

When a long bone and an adjacent joint are involved it is better to undertake the
reconstruction in two stages. As a matter of fact, the bone should have healed before
commencing with the restoration of joint motion or performing joint fusion.
Procedures for reconstruction of the bone

• Cortical or cancellous bone graft, bone substitutes, vascularized bone transfer, bone
transport, large allograft.
• Large defects can be reconstructed with conventional cancellous bone grafts provided
a cement spacer has been inserted prior to the graft procedure to induce a foreign body
membrane which prevents the resorption of the graft (Masquelet et al 2002).
• Techniques of bone fixation should be considered according to the length of the
defect, the quality of soft tissue and the procedure of bone reconstruction.
Procedures for reconstruction of the joints

The reconstruction of the joints does not necessarily mean to restore motion. Joint fusion
should be considered as a particular case of joint reconstruction. Obviously joint fusion
with a bone defect raises difficult problems of reconstruction.
Procedures to reconstruct a joint can be summarized as follows: arthrolysis, joint
fusion, arthroplasties. Arthroplasties constitute a vast subject which comprises prosthetic
replacements, bone extremities remodelling, tissue interposition, etc.
The restoration of function

This is the final goal of treatment once the skin envelope is repaired and bone stability
and joint motion have been achieved.
Figure 6
Skin and tendon necrosis by a chemotherapeutic agent in a
65-year-old patient. The MP (metacarpophalangeal) joints
were stiff.
Function involves the muscles, the tendons and the nerves. A tendon transfer cannot
be performed before having repaired the skin envelope and restoring joint motion. In
most cases, tendon grafting and tendon transfers should be prepared by setting silicone
rods to induce a gliding sheath according to Hunter’s technique (Case 2) (Hunter and
Jaeger 1977). However, in some cases, procedures on nerves must be performed very
early in the plan of reconstructive surgery. For instance, in a case of Volkmann
syndrome, the first procedure to be undertaken is the release of the nerves to obtain
recovery of sensory function.
Procedures on nerves include: neurolysis, conventional nerve grafts, vascularized
nerve grafts, nerve allografts, special techniques (nerve expansion, end-to-side
anastomosis).
Procedures on tendons include: tenolysis, tendon graft, artificial tendons.
Procedures for restoring active motion (in case of paralysis) include: muscle tendon
unit transfer and free muscle transfer. It is to be noted that when we use a free muscle
transfer, the soft tissue defect is treated in the same stage as the functional impairment.
Case 2 (Figures 6–10)

This is a compound defect of the dorsum of the hand involving the skin envelope and
extensor tendons.
Figure 7
Prior to reconstruction several iterative debridements and
excisions were undertaken. Extensor tendons of the fingers
were excised.
Figure 8
The first stage involved soft tissue repair. This was by a

distally based radial forearm flap which has the advantage
of improving the blood supply of the recipient site.
Figure 9
(a,b) The second stage consisted of the release of the MP
joints associated with the setting of silicone rods under the
flap according to Hunter’s technique.
Figure 10
(a) The final stage was tendon grafting by using extensor
tendons of the toes. (b) Clinical result.
Conclusion
Reconstructive surgery of a compound defect which involves functional impairment is

based on the following points:
• A precise assessment of the tissue injuries and functional impairment.
• The final function that we can hope to obtain after surgery.
• The planning of the reconstruction.
• The choice of surgical techniques.
Reconstructive surgery requires maximal cooperation between the surgeon and the
patient.
References
Hunter JM, Jaeger SH (1977) Tendon implants: primary and secondary usage, Orthop
Clin North Am 8:473–89.
Lister G, Schecker L (1988) Emergency free flaps to the upper extremity, J Hand Surg
13A:22–8.
Masquelet AC, Fitoussi F, Begue T, Muller GP (2002) Reconstruction des os longs par
membrane induite et autogreffe spongieuse, Ann Chir Plast Esthet 45: 346–53.
Michon J, Foucher G, Merle M (1977) Traumatismes complexes de la main. Traitement
‘tout en un temps’ avec mobilisation précoce, Chirurgie 103:956–64.
23
Surgical management of infection
Manuel Llusa, Xavier Mir and Xavier Flores
Introduction
Management of severe traumatic defects of the upper limb presents an important

challenge to orthopaedic and plastic surgeons. Recent advances in reconstructive
microsurgery have made it possible to transfer free cutaneous, muscle, myocutaneous,
fasciocutaneous, bone and osteocutaneous flaps to solve a wide spectrum of post-
traumatic defects. All of these complex techniques, and even the more simple surgeries
require a previously clean wound to obtain a good result.
Ideally, infection should be avoided but the kind of high-energy trauma that results in
fractures and soft tissue injuries with high wound contamination make it difficult to
prevent infection. Management protocols for acute situations begin with irrigation,
debridement and stabilization of the fractures as soon as possible. Infected fractures
require similar radical treatment. In fact, all patients with open fractures should be
considered as being infected.
Irrigation and debridement
Predebridement cultures are taken and gross debris cleaned by irrigating the wound
profusely with sterile saline solution (up to 10 litres of normal saline). The majority of
authors recommend a mechanical irrigating system with pulsating or jet lavage (Gustilo
1989, Johnson 1989).
After the initial cultures, intravenous antibiotic therapy is begun depending on the
prophylactic protocol (see Antibiotic treatment at the end of the chapter). With open
fractures bacterial contamination is present 65–75% of the time. It should be emphasized
that emergency cultures have little correlation with organisms isolated from infected
wounds (Gustilo 1990, Seekamp et al 2000). Wound cultures should be taken from the
deeper part of the wound. Cultures taken superficially or from inside the sinus tract, in
chronic cases, can be misleading and bear no relation to the infecting organism inside the
deep part of the wound (Gustilo 1989). The most significant infecting organisms in high-
energy fractures are Gram-negative rods (75%) or the same along with Gram-positive
organisms (24%) (Johnson 1989).
Following initial irrigation the draping of the extremity is changed and debridement is
performed. Generally tourniquet is not applied in order to distinguish between viable and
nonviable tissue.
Debridement must be radical including all devitalized tissues and devascularized bone
fragments with the exception of intraarticular fragments with cartilage, if possible, to
preserve future joint function. Some authors suggest that debridement must be very
aggressive, such as when ablating tumours (Tomaino 1999). However, we think that the
debridement must be radical but functional, trying to conserve at least the basic elements
for future movement if possible. The real soft tissue injury is usually more extensive than
initially appreciated. Serial debridements repeated every 48–72 hours permit the surgeon
to define the real extent of the wound (Weiland and Yaremchuck 1990). On other
occasions, severe and frank infections make it obligatory to perform a one-stage wide and
radical debridement with composite tissue loss—combination of soft tissue, tendon, nerve
and bone (Fig. 1).
Extensive bone fragmentation should be carefully evaluated. Devascularized bone
fragments with no soft tissue attachments should be
Figure 1
Severe infection of the dorsum of the hand and wrist
affecting soft tissue, tendons, muscle and bones—
composite tissue loss.
removed without hesitation. Currently the availability of cancellous or free bone grafting
(microvascular fibular or iliac crest) or bone transport gives the surgeon confidence that
the bone defects can be reconstructed later (Wood and Gilbert 1977, Gerwin and Weiland
1992).
Fracture stabilization
Once final debridement is completed fracture stabilization is performed. It has been

demonstrated that early fracture stabilization reduces wound infection rates (Anderson
and Meyer 1993). External fixation devices can be used in the majority of cases. They are
easy to apply, allow daily wound care and serial debridements, and permit secondary
procedures such as skin closure and plastic surgery procedures for wound coverage when
infection has been eradicated (Fig. 2) (Wild et al 1982, Soucacos et al 1995).
The techniques used to achieve fracture stability in upper extremity fractures differ
from those for lower extremity fractures. Primary internal fixation, by plating or
intramedullary nailing, can be used in diaphyseal fractures, in cases with low risk of
infection due to the rich blood supply and abundant soft tissue envelope, especially in
Surgical management of infection 379
humerus and forearm fractures (Tomaino 1999). Plating is a good option in fractures
around epiphyseometaphyseal bone. At the level of the
Figure 2
Fracture stabilization with external fixation facilitates skin
coverage and plastic procedures.
hand Kirschner wires are a fast and safe option (Tomaino 1999).
In the presence of infection, if the internal fixation device is loose and the fracture
becomes unstable, it should be removed and changed to external fixation after wide
debridement. But if the internal fixation provides rigid fracture stability it can be
maintained even if it is exposed (Gustilo 1990). Internal fixation has the advantage of
permitting easy care for soft tissue problems, and avoids the risk of pin track sepsis often
seen with external devices. If there is any doubt we prefer to apply an external fixation
and later change to internal fixation as soon as possible (when signs and symptoms of
infection have subsided) to avoid pin track infection (Figs 3–5).
Figure 3
Elbow open fracture grade IIIC with severe bone loss.
Ipsilateral fracture of the radius and ulna.
Figure 4
Temporary external fixation application as an emergency
treatment after debridement. Brachial artery reconstruction
was needed.
When pin sepsis occurs changes to secondary plating or intramedullary nailing have a
high risk of infection (Gustilo 1990). Antibiotic therapy and a delay of 48–72 hours after
external fixation removal is recommended. Some authors do not recommend
intramedullary reaming because of the risk of pandiaphyseal osteomyelitis, and others use
unreamed intramedullary nails, especially in the humerus (Gustilo 1990).
If any kind of osteosynthesis is in place and functioning properly, without any sign of
loosening, it should be left in place and an aggressive debridement carried out. Radical
excision of necrotic skin, non-viable tissues and debride
Figure 5
Early elbow arthrodesis due to wide soft tissue loss.
Options such as elbow allograft or elbow prosthesis should
be considered. This patient refused these options.
ment of necrotic bone are performed until viable tissue and a clean wound are obtained.
This step should be done without a tourniquet.
Defect coverage
Initially no attempt to close the wound should be made, unless the surgeon’s experience
recommends the contrary. Generally it is very difficult to assess, during the initial
treatment, the degree of contamination and vascularization of the injured area. We prefer
to perform a second look and several debridements, especially in polytraumatic patients,
because of the high infection rates. Surgically induced wounds may be closed if there is
no tension on the soft tissue. However, the wound in the area of the open fracture should
not be closed (Johnson 1989).
Timing of wound closure depends on several factors but generally it is possible within
the first few days to a fortnight; the management varies from delayed primary or
secondary closure to local flaps or microvascular free flaps (Soucacos et al 1995). In
cases with unprotected neurovascular structures additional procedures should be done in

order to cover the vital nerves and vessels (Varecka 1989).
Initially the wound is left wide open or packed with polymethylmethacrylate beads
impregnated with gentamicin sulphate to fill dead space. Recently, biodegradable
delivery systems have been used (Klemm 1993).
The technique of open healing by secondary intention results in a densely fibrotic
wound, increasing the susceptibility to ischaemic complications and decreasing the
functionality of the affected extremity. The technique of Papineau is not recommended
except in very special situations (Weiland and Yaremchuk 1990).
There is a consensus that generally it is better to proceed to early or delayed primary
wound closure or coverage with local, or even better, with free muscle transfer within the
first week (Gerwin and Weiland 1992). The dead space is filled with
polymethylmethacrylate beads (Klemm 1987) or, as has been proposed, with an
antibiotic-impregnated cement block (Masquelet et al 2000), not only to deliver
antimicrobial agents but also to provide some restoration of integrity and stability.
Ideally free muscle flap (latissimus dorsi or rectus abdominis) is adapted to cover the
wound and fill the rest of the dead space. The muscle flap is covered with a meshed split
thickness skin graft. Cutaneous or fasciocutaneous flaps are not used because of their
inability to adapt and fill dead space. The muscle provides a rich vascular supply and
creates an induced membrane over the polymethylmethacrylate cement block (Masquelet
et al 2000). After a period of 4–6 weeks the cement block is removed and, if the wound is
clean without any sign of infection, bone grafting is performed. Stevanovic et al (1999)
recommend autogenous cancellous bone in small or moderate defects and microvascular
bone transfer in cases of segmental defects greater than 6 cm. The recipient site should be
explored prior to obtaining the bone graft to remove any occult infection. The increase in
blood supply brought by the microvascular muscle transfer aids in the control of infection
and in the rapid incorporation of the cancellous bone graft. Chan et al (2000) suggest that
antibiotic-impregnated autogenous bone grafting is an effective and safe method for the
management of small bone defects and it does not have any adverse effects on bone graft
incorporation.
Simultaneous cancellous bone grafting and muscle flap closure should be avoided
because of the risk of bacterial contamination at the time of closure and possible
reinfection. In some situations one-stage soft tissue reconstruction with a free
osteomyocutaneous flap has been suggested by some authors (Godina 1986).
A practical point to remember is to get in touch with the plastic surgeon as soon as
possible when a free soft tissue flap is indicated, so that it can be planned in advance.
This should be within the first 3–7 days of injury, when the wound is in optimal
condition.
In some special situations creation of a one bone forearm may be indicated. This
technique sacrifices prono-supination. Reported results indicate a less than ideal outcome
but it should be borne in mind when treating a difficult combination of bone and soft
tissue injury with loss of the distal radio-ulnar joint (Stevanovic et al 1999). In Figures 6–
10 we summarize some of the
Figure 6
A young male with an open grade IIIC ulna and radius
fracture. Severe infection was present with bone and soft
tissue loss. Serial debridements were performed. Cultures
isolated Clostridium perfringens.
Figure 7
Radiographs of the same case as in Fig. 6.
Figure 8
Radical debridement, free latissimus dorsi transfer and
reapplication of the external fixation.
basic concepts of the surgical management of infection in a severe post-traumatic case.
Antibiotic treatment
The most satisfactory prophylactic procedure to prevent infection in open fractures is

prompt, adequate surgical debridement and antibiotics are no substitute for this (Johnson
1989). Theoretically, prophylactic antibiotic therapy should not be initiated until surgical
debridement and samples for cultures have been taken. However, due to the high
frequency of bacterial contamination, the use of antibiotics for a conta
Figure 9
Four weeks later there were no signs of infection and bone
grafting and osteosynthesis were performed with creation
of a one bone forearm.
Figure 10
Final appearance with resolution of the infection, even
though prono-supination was lost.
minated wound is defined as active therapy and not as prophylaxis (Johnson 1999).
Appropriate therapy should be selected according to the organisms cultured in each
specific case.
The following empirical recommendations can be made for antibiotic treatment of

open fractures and soft tissue injuries, depending on the degree and type of
contamination:
• Minimally contaminated soft tissue injuries and type I and type II open fractures
should be treated with a first generation cephalosporin (usually cefazolin) or a
combination of amoxicillin and clavulanate.
• Severely contaminated soft tissue injuries and contaminated type II fractures and all
type III open fractures should be treated with a combination of a first generation
cephalosporin with an intravenous aminoglycoside (gentamicin or tobramycin). The
use of a third generation cephalosporin, such as cefotaxime, is a good option. This
antibiotic is very effective against Gram-negative organisms and also against Gram-
positive organisms compared with other third generation cephalosporins. Its use
avoids the risks and side effects of aminoglycosides. However, it should be
remembered that most of the third generation cephalosporins do not cover
Pseudomonas spp. as well as the aminoglycosides. Currently, the use of
amoxicillin/clavulanate is also considered a good choice in empirical antibiotic
treatment of type III open fractures, except in cases with risk of Pseudomonas
contamination or infection. In such a situation gentamicin must be part of the
antibiotic therapy.
Generally prophylactic antibiotics are administred for 48–72 hours. In severe cases with
generalized sepsis a penicillinase-resistant synthetic penicillin (cloxacillin 2 gm every 4
hours iv) in combination with an antipseudomonal aminoglycosidic antibiotic
(gentamicin or tobramycin, 80 mg every 8 hours iv) plus clindamycin (900 mg every 8
hours iv) should be administered. Generally these complex cases are managed by
intensive care unit specialists.
In postoperative infections, after fracture reduction and internal fixation,
Staphylococcus aureus, Enterobacteriaceae or Pseudomonas spp. are usually isolated. In
these cases a combination of cloxacillin (2 gm every 4 hours iv) with ciprofloxacin (750
mg every 12 hours po) should be considered or a combination of ciprofloxacin (750 mg
every 12 hours po) with rifampicin (300–600 mg every 8 hours po).
When Staphylococcus epidermidis is isolated the appropriate antibiotic is vancomycin
(1 gm every 12 hours iv) and all foreign bodies such as sutures, hardware or
osteosynthesis must be removed.
Once the infection has resolved antibiotic therapy should be restarted as a prophylactic
measure for the following circumstances:
• During delayed primary or secondary wound closure, including free flap transfers.
• When internal fixation or open reduction and osteosynthesis are performed.
• When external fixation is changed to internal fixation (plates or intramedullary
nailing).
In most cases, patients are already on broadspectrum antibiotic treatment because of
previous signs and symptoms of infection, prior to microorganism identification and are
then put on specific treatment adapted to their indivdual situation. At this point, we
recommend collaborating with an infectious disease specialist in complex cases with
antibiotic-resistant microorganisms or in cases with severe medical problems. These
situations demand wide experience in systemic antibiotic management.
Antibiotic therapy is recommended until adequate soft tissue healing has been
achieved; usually this may take from 3–6 weeks.
References
Anderson LD, Meyers FN (1993) Management of infected implants. In: Chapman MW,
Madison M, eds. Operative Orthopaedics, 2nd edn. JB Lippincott: Philadelphia,
3385–407.
Chan Y, Ueng SW, Wang C et al (2000) Antibioticimpregnated autogeneic cancellous
bone grafting is an effective and safe method for the management of small infected
tibial defects. A comparison study, J Trauma 48:246–55.
Gerwin M, Weiland AJ (1992) Vascularized bone grafts to the upper extremity.
Indications and technique , Hand Clin 8:509–23.
Gilbert DN, Moellering RC, Sande MA (1999) Terapéutica antimicrobiana empírica.
Fármacos antimicrobianos de elección frente a microorganismos. In: Sanford JP, ed.
Guía de Terapéutica Antimicrobiana. Ediciones Díaz de Santos SA: Madrid, 4–61.
Gustilo RB (1989) Management of open fractures. In: Gustilo RB, ed. Orthopaedic
Infection. Diagnosis and Treatment. WB Saunders: Philadelphia, 87–117.
Gustilo RB (1990) Management of infected fractures. In: Evarts CM, ed. Surgery of the
Musculoskeletal System. Churchill Livingstone: New York, 4429–54.
Johnson K (1989) Management of open fractures and infections. In: D’Ambrosia RD,
Marier RL, eds. Orthopaedic Infections. Slack Incorporated: New Jersey, 517–28.
Klemm KW (1993) Antibiotic bead chains, Clin Orthop 295:63–6.
Klemm K (1997) Clinical applications of gentamicinPMMA beads. In: Coombs R,
Fitzgerald RH, eds. Infection in the Orthopaedic Patient. Butterworths: London, 167–
77.
Kumar VP, Satku K, Helm R, Pho RW (1988) Radial reconstruction in segmental defects
of both forearm bones, J Bone Joint Surg 70B:815–17.
Masquelet AC, Fitoussi F, Begue T, Muller GP (2000) Reconstruction of the long bones
by the induced membrane and spongy autograft, Ann Chir Plast Esthet 45:346–53.
Seekamp A, Köntopp H, Schandelmaier P, Krettek C, Tscherne H (2000) Bacterial
cultures and bacterial infections in open fractures, Eur J Trauma 26:131–8.
Soucacos PN, Beris AE, Xenakis TA, Malizos KN, Vekris MD (1995) Open Type IIIB
and IIIC fractures treated by an orthopaedic microsurgical team, Clin Orthop 314:59–
66.
Stevanovic M, Gutow AP, Sharpe F (1999) The management of bone defects of the
forearm after trauma, Hand Clin 15:299–318.
Tomaino MM (1999) Treatment of composite tissue loss following hand and forearm
trauma, Hand Clin 15:319–33.
Varecka TF (1989) Soft tissue coverage in open fractures. In: Gustilo RB, ed.
Orthopaedic Infection. Diagnosis and Treatment. WB Saunders: Philadelphia, 118–
22.
Weiland AJ, Yaremchuk MJ (1990) Management of traumatic osteocutaneous defects in
the lower extremity. In: Evarts CM, ed. Surgery of the Musculoskeletal System.
Churchill Livingstone: New York, 4525–55.
24
Reconstruction of large defects of the upper
limb in children
Massimo Ceruso, Filippo M Sènés, Giuseppe Checcucci, Prospero
Bigazzi, Alessandra Allegra and Gloria Taliani
Introduction
Severe post-traumatic defects in the upper limbs of children are rather rare. Literature on
the subject is scarce and it is difficult to conduct an exhaustive review because of the
heterogeneity of the reported series. While there is reasonable agreement on indications
and surgical strategies, data on complications and failures are quite diverse (Canales et al
1991, Raimondi et al 2000, Romaña et al 2000, Yücel et al 2001). Furthermore, the
special consideration for anaesthesia and pharmacological treatment of the young patient
are rarely discussed (Bell et al 1992, Mollit 2002).
In fact, the differences in the anatomy of a child compared to an adult and their growth
must be taken into consideration while planning any reconstructive treatment in children.
Aetiopathogenesis
The incidence, characteristics and effects of highenergy trauma are different in the
growing individual than in the adult.
Severe post-traumatic defects of the upper limb in adults are mostly related to work,
traffic, or sports-related accidents. In children, these types of injury occur less frequently
and when they happen they are caused by catastrophic events (e.g. explosions or collapse
of buildings) or serious traffic accidents in which children are involved either as
passengers in a vehicle, or as pedestrians hit by a vehicle. Domestic accidents may cause
lesions from crushing and avulsion. In these instances, owing to the small size of the
limbs, the traumatizing agent often damages the tissues, transforming a sharp cut into a
crush injury. In high-energy trauma, the child is more vulnerable to injuries in multiple
areas of the body. Limb injuries are frequently associated with visceral involvement
(cranio-encephalic, spleen and kidney lesions), which often make lifesaving procedures a
higher priority than reconstructive procedures.
There is, therefore, a distinction between the patient with multiple trauma, which is
relatively frequent, and the isolated severe lesion of the upper limb, which is rather rare.
Upper limb lesions are frequently observed in conjunction with trauma at the level of the
trunk; in traffic accidents this happens owing to both the seated position in the back seat
and the upper limb being generally close to the thorax and thus more easily compressed
or injured by parts of the vehicle’s cab.
Reconstruction of large defects of the upper limb in children 389
Extensive burns are also one of the more frequent causes of lesions in children and
occur especially because of thermal injuries to the upper limb, whereas electric or caustic
burns are almost exclusively limited to the hand.
Severe soft tissues lesions can be isolated or associated with neurovascular lesions
and/or exposed fractures (with or without loss of bone substance); the latter are more
frequently observed (Fried et al 1978, Holmes and Reyes 1984, Mazurek 1991,
Ramenofsky and Moulton 1995, Weinberg et al 1999, Moulton 2000, Fagelman et al
2002).
Indications
It is agreed that indications for surgical reconstruction of severe post-traumatic defects in

children, as well as for replantation of amputated segments, are wider than in adults
because of the expected lifespan of the patient, for the aesthetic and social value of the
reconstruction and finally because the prospects of functional recovery are higher (Paul et
al 1997, Raimondi et al 2000).
Obviously, more generalized indications for reconstructive surgery lead to a greater
incidence of complications and failures. The success rate of replantations in adults is
reported to be higher than 80%, whereas in children it is lower than 70% (Urbaniak and
Foster 1992). Conflicting data are found in the articles specifically dedicated to
microsurgical flaps in children (Iwaya et al 1982, Banic and Wulf 1986, Shapiro et al
1989, Canales et al 1991). In view of improved surgical and anaesthesiological
techniques, more recent reviews suggest rates of success closer to those for adults (95%,
Yücel et al 2001).
Anaesthetic considerations
A child is not simply a small adult: their anatomy, physiology, and pharmacokinetics are
completely different. Therefore, paediatric anaesthesia may be very difficult and requires
special skills.
Orthopaedic lesions are frequent in children and severe trauma is the leading cause of
death and disability in children older than 12 months. Severe crush injuries to the limb
may be life threatening for the associated blood loss can lead to cardiovascular collapse.
The initial care of the child patient is organized systematically and is based on the
paediatric advanced life support (PALS) and advanced trauma life support (ATLS)
protocols. A complete examination in a minimally stabilized patient can be made before
establishing the surgical therapeutic strategy. As soon as temporary haemostasis has been
achieved by the surgical team, fluid volume replacement must be initiated by means of an
intravenous line. It is always easier and less time consuming to insert a short catheter in
the early stages of progressive shock. Intraosseous infusion is recommended for
emergency vascular access in advanced paediatric trauma life support protocols: it allows
perfusion of crystalloid solutions, blood products and even emergency drugs into the
marrow space of the proximal tibia, when attempts to establish other routes have failed.
Once vital functions are stable, we need to ensure that the child is calm and cooperative
to perform a complete examination of the lesion. An anxious patient complicates the

assessment. Preoperative anxiety also activates the human stress response, leading to
increased serum cortisol and epinephrine; it is associated with arterial pressure
alterations, likelihood of vasospasm, susceptibility to infection and delayed wound
healing.
Children are particularly vulnerable to the general surgical stress response.
Premedication with oral midazolam seems to decrease the incidence of negative
behavioural changes during the first week after surgery. This may be particularly
significant for children undergoing repeated surgical procedures. Parental presence
during induction of anaesthesia and during recovery should be allowed to minimize
postoperative behavioural disturbances (McCann and Kain 2001). Finally, alleviating
parental anxiety will alleviate child anxiety.
Once light general anaesthesia is induced, a nerve block can provide most of the
analgesia. In the perioperative period, it is mandatory to keep tissue perfusion constant,
particularly when microsurgical flaps or a replantation are being performed.
Vasoconstriction may occur because of many reasons like hypothermia, crying, pain, so
the child must be kept warm, calm and pain free. It is useful to consider a continuous
brachial plexus anaesthetic block with an axillary catheter. This produces pain control
and induces a pharmacological sympathetic paralysis during and after surgery, and can be
used therapeutically for improving perfusion. Electrical stimulation of nerves can be used
to help while giving the nerve block.
Temperature control is important during anaesthesia, especially in small children.
They have a larger surface area to weight ratio than adults and consequently cool down
more rapidly. There is a tendency to progressive heat loss during an operation, especially
if large areas of the body are exposed. Therefore, in children the use of a warming
blanket, warmed perfusion solution and warmed, humidified gases is beneficial. An
interesting cause of body temperature variation is (if being used) the tourniquet: the
exposed limb below the tourniquet becomes cool from contact with air. When the
tourniquet is released, blood circulates through the cold limb resulting in a fall of body
temperature over the next 5 minutes, which can induce peripheral vasoconstriction.
Intraoperative blood loss must be carefully evaluated because hypovolemia may lead
to decreased tissue perfusion. The total blood volume is estimated to be about 70 ml/kg
for a child and 80 ml/kg for an infant. Whenever haemorrhage occurs, children maintain
adequate arterial blood pressure by efficient compensatory sympathetic-mediated
vasoconstriction and tachycardia. Signs of shock are initially subtle and are evident
clinically only when the compensatory mechanisms begin to fail. Red cell transfusion is
required to meet tissue oxygen demands and maintain the metabolic rate; in any case a
moderate normovolemic haemodilution is useful to improve microcirculatory flow, by
reducing the haematocrit while maintaining intravascular volume to ensure adequate
cardiac output. Blood viscosity is reduced as a consequence of the fall in haematocrit, and
results in decreased systemic vascular resistance, increased blood flow and increased
systemic oxygen transport. It is generally agreed that it is necessary to maintain a
haematocrit above 30% for the infant and 26% for the older child.
Surgical treatment
Soft tissue defects

Some anatomical peculiarities of children’s tissues affect the technique of harvesting
vascularized flaps and may influence long-term results of microsurgical reconstructions.
The subcutaneous fat tissue is trophic and abundant in infants; moreover, it is scarcely
vascularized and fragile. An atraumatic technique is necessary to avoid ischaemia of the
fat layer, which may lead to necrosis and infection. Furthermore, the dissection of
composite flaps is more difficult than in adults because of the tendency of the
subcutaneous layer to separate from the underlying muscle or fascia.
Cutaneous and composite flaps tend to be thicker in children; this should be kept in
mind while deciding which flap to use for the reconstruction of the overall defect. Such
flaps tend to increase in volume during childhood growth (allegedly owing to their rich
vascularization), whereas muscular flaps tend to retract and become fibrotic with time.
Consequently, skin flaps are preferred in reconstructions of articular or paraarticular areas
so as not to interfere with joint motion, whereas muscular flaps should be chosen to cover
non-mobile areas, such as the diaphyseal segment of a limb (Romaña et al 2000).
The latissimus dorsi flap is most frequently used to reconstruct large upper limb
defects. It can be used both as a pedicled flap—for reconstructions in the shoulder area—
or as a free flap in larger distal defects. Furthermore it may be used as a functional
muscle transfer, keeping its motor nerve intact, to reconstruct an avulsed or paralysed
deltoid or biceps muscle.
The scapular and parascapular flaps are good options for medium-sized
reconstructions. Their major drawback is a rather short vascular pedicle which quite
frequently shows anatomical variations. Moreover, in the donor area, the aesthetics are
poor as the scar worsens with time because of the progressive stretching due to childhood
growth.
The radial forearm flap has few or no indications because it requires the sacrifice of
the radial artery, which in the child takes on greater significance in later life. It can be
considered in special cases, such as in the form of a flowthrough composite flap to
replant or revascularize an ischaemic distal segment through an arterial graft.
The posterior interosseous flap poses greater difficulties in terms of harvesting
technique, especially in smaller children. It can be used as a direct flow pedicle flap for
proximal defects or, more commonly, as a reverse flow flap for distal upper limb
reconstructions. Becker’s ulnar flap has more limited indications, although it leaves less
scarring. Becker and Gibert (1990) report the possibility of using it as a free flap which is
based on a pedicle that includes a short segment of the ulnar artery. This can later be re-
anastomosed owing to its elasticity. The lateral arm flap may also be a possible choice for
the reconstructive surgery. It has a constant and long vascular pedicle and can be chosen
for the reconstruction of thick medium-sized defects.
The dorsalis pedis flap still is useful for smallto-medium reconstructions of the wrist
and hand when a thin and elastic flap is needed. It is particularly useful as a composite
flap including the vascularized toe extensor tendons, or as an osteocutaneous flap that
includes one of the metatarsals. The donor site scarring is not as bad as commonly
described if the flap is properly designed and the thickness of the split skin graft used for
the secondary reconstruction is adequate. An innervated gracilis muscle transfer is
indicated in severe forearm muscular tissue loss, as well as in sequelae of Volkmann’s
syndrome. It can be harvested as a pure muscular or a myocutaneous flap. Its motor
reinnervation allows the recovery of a functional grip depending on different
reconstructive options.
Finally, when a free microsurgical flap is not feasible, the possibility of using more
traditional axial flaps can be still be considered. In particular, McGregor’s groin flap
allows the covering of the distal forearm; wrist and dorsal or volar aspects of the hand,
with minimal aesthetic damage in the donor area. This remains, however, a second option
because of the discomfort of immobilizing the small patient with a bandage or cast for
several weeks and the necessity of changing the wound dressing frequently.
Bone and articular defects

Extensive skeletal lesions of the upper limb can affect bone growth by damaging the
epiphyseal plates, or thwarting their growth potential leading to secondary axial
deviations or, paradoxically, to hypergrowth due to excessive stimulus of the physis.
These all are conditions peculiar to the paediatric patient.
A vascularized epiphyseal transfer, together with a variable length of the diaphyseal
segment, makes it possible to restore the axial growth of the bones of young patients
whose epiphysis has been destroyed by trauma, infections, or tumour resection. The
proximal fibula is particularly well suited to reconstruction of the proximal humerus and
of the distal radius because of the similarities in size and shape. Furthermore, a
vascularized bone graft has greater resistance to infection because of its inherent blood
supply.
The choice of the vascular pedicle in epiphyseal fibula transfers has been a subject of
discussion. Some authors utilize the peroneal artery, isolated or in association with the
geniculate inferior lateral artery (Tsai et al 1986, Gilbert and Mathoulin 2000), whereas
others prefer the anterior tibial pedicle. The latter is able to vascularize both the proximal
epiphysis and the proximal two-thirds of the diaphysis (Taylor et al 1988). Our clinical
experience has convinced us that the anterior tibial pedicle permits a predictable growth
of the graft (Fig.1) (Innocenti et al 1998).
Articular reconstructions as well should be planned taking skeletal growth into
account. Temporary restoration of skeletal length of the limb is obtained through external
fixation. Associated soft tissue reconstruction is through
Figure 1
Reconstruction of the distal radius with a vascularized
fibula graft in a 7-year-old child after bone sarcoma
resection. The transfer was based on the anterior tibial
vascular pedicle. (a) Radiograph at 4 months. (b) After 3
years the graft growth was 2.5 cm (growth rate per year:
0.9 cm).
pedicled or free vascularized flaps. Coexisting nerve or vascular lesions are also repaired.
Large bone defects can be treated by immediate microsurgical composite osteocutaneous
flaps. As an alternative, temporary cement spacers with antibiotics can be used. The wrist
and the digital joints may be treated with immediate arthrodesis supported with
cancellous bone grafts.
Elbow joint reconstruction poses greater functional problems because rigidity leads to
a severe functional impairment. In these instances, a vascularized transplant of the first
metatarsophalangeal joint has proved to be effective (Ceruso et al 2000). A stable joint
with a functional range of motion can be achieved (Fig. 2). Similarly, in multiple digit
trauma, there may be an indication for a vascularized metatarsophalangeal joint transfer
to restore the mobility of at least one of the digital rays.
Peripheral nerve lesions

‘Recovery in children is far better than adults and there should, therefore, be no hesitation
in embarking on the repair of proximally situated
Figure 2
Septic arthritis of the elbow joint. (a) Radiograph showing
secondary elbow dislocation and bone deformity at the age
of 14. (b,c) AP and lateral views after reconstruction with
a vascularized metatarsophalangeal joint transfer from the
big toe. (d) Range of motion of the reconstructed elbow at
5-year follow-up. (e) First metatarsal ray reconstruction
with an iliac bone graft. (f) The donor foot at 5 years.
Figure 3
(a) Traumatic left arm amputation in a 7-year-old child.
(b–d) The progression of nerve regeneration and complete
intrinsic muscle recovery.
lesions in the young’ (Seddon 1975). More recent studies also support the view that
peripheral nerve repair in children is always aided by favourable biological factors (Birch
and Achan 2000). Nerve regeneration occurs in considerably shorter time in comparison
to adult patients; excellent sensory recovery can be expected and motor reinnervation of
the intrinsic muscles of the hand can be achieved (Fig. 3). Furthermore, in children we
observe neither hypersensitivity to cold nor posttraumatic neuralgia or the painful
hypersensitivity that accompanies regeneration of a trunk nerve. Finally, causalgia and
reflex sympathetic dystrophy are scarcely ever seen in a paediatric patient (Stevenson and
Zucker 1986). Therefore, immediate exploration and repair of the nerve lesion, through
direct microscopic suture or grafts, should always be performed even in proximal
avulsion injuries.
In some instances it may be difficult to perform an adequate evaluation of the extent
and complexity of nerve lesions in children and treatment could be delayed owing to an
erroneous belief in spontaneous recovery. It must be kept in mind that nerve lesions
interfere with the growth of the limb and may lead to secondary osteoarticular
deformities owing to the alteration of muscular balance.
After repair, nerve regeneration may go on for an unusually long time. Therefore,
secondary palliative operations, such as tendon transfers, must be delayed longer than in
the adult.
Antibiotic treatment
Infection is the most frequently recognized cause of morbidity in severely injured

children. However, it should not be considered as an inevitable consequence of injury.
Exogenous, environmental or endogenous pathogens can be involved and polymicrobial
aetiology accounts for nearly half of the infections. Among the paediatric trauma patients
the overall incidence of infections is nearly 10% and approximately 1% of deaths are
related to sepsis (Bell et al 1992). These figures are low compared to those reported
among adults. Different factors contribute to the risk of infection, including disruption of
cutaneous barriers, devitalization of tissue by trauma, reduction of chemotaxis,
impairment of reticuloendothelial function and intracellular killing, and alteration of T
and B cell responses. These factors act in conjunction with bacterial contamination by
foreign debris and/or bacterial overgrowth due to intestinal and urinary stasis (Mollit
2002).
In traumatically wounded children antibiotic treatment cannot be considered
prophylactic, since tissue injury and contamination have already occurred at the time the
antibiotic therapy is started. Its role is, therefore, to control infection, particularly in the
presence of severe contamination, widespread tissue damage, abundant local flora and
delay in surgical and medical treatment. In fact, all these factors favour the onset of
infection. The recommended route of administration of the antibiotic therapy is the
intravenous route which allows better efficacy with shorter duration of treatment.
In presence of sharp, penetrating trauma or complex blunt injuries involving only skin
and/or soft tissue, a latent period of approximately 4 hours exists before bacterial growth
and tissue invasion occurs and at least 6–8 hours are necessary for infection to develop.
In these instances, provided that the intervention is timely (unless an animal bite is
responsible for the wound) a single dose of an antistaphylococcal agent may be sufficient
for prophylaxis of infection. In the case of bite wounds, in which Staphylococcus aureus,
streptococci, anaerobes and Pasteurella spp. are usually involved, intravenous treatment
with amoxicillin-clavulanate or ampicillin-sulbactam is recommended for at least 48–72
hours (American Academy of Pediatrics 2000).
When stretch, compression or crush injuries are associated with open fractures,
contamination with skin flora and/or other pathogens derived from clothes, soil or debris
occurs immediately. These injuries are therefore at risk of soft tissue infection and of
osteomyelitis. The most commonly involved pathogens are Staphylococcus, Gram-
negative rods, Pseudomonas and Clostridium. Antibiotic treatment is administered
according to the extent of the tissue wound, crushing and vascular injury. In particular, in
children, when the tissue wound is greater than 1 cm and crushing injury with or without
massive contamination or vascular injury are also present, an aminoglycoside is added
and the treatment is continued for longer than 72 hours. In the presence of an extensive
crush injury or soil or faecal contamination, which increase the risk of clostridial
infection, penicillin is also given (Table 1) (Behrens 1998).
Tetanus prophylaxis is indicated in all children with any soft tissue injuries.
Complications
The smaller dimensions of the vessels in children are generally cited as one of the
unfavourable elements for the success of a microsurgical reconstructive procedure. In
spite of the improvement of microsurgical techniques, there remain objective limits to
performing reliable anastomosis of vessels below 0.8 mm in diameter (Romaña et al
2000). It must be noted however, that there is a favourable relationship between the
overall dimensions of the injured limb and the diameter of the vessels, since the vessels
and nerves of children are proportionally larger than in the adult, the level of lesion being
similar.
Favourable prognostic factors are reported to be the decreased tendency for spasm and
vascular thrombosis because risk factors such as diabetes, arterial hypertension,
associated cardiovascular pathologies, smoking, are absent or rare (Parry et al 1998).
Nevertheless, the percentage
Table 1 Paediatric doses of selected antibiotics.

Doses in mg/kg at frequency indicated
Body weight < Body weight >
Drug
2000 gm 2000 gm
0–7 days 8–28 0–7 days 8–28 > 28 days
days days
Amikacin 7.5 q 18– 7.5 q 18– 10 q 12h 10 q 12h 10 q 8h
24h 24h
Gent/tobra 2.5 q 18– 2.5 q 18– 2.5 q 12h 2.5 q 12h 2.5 q 8h
24h 24h
Cefazolin 20 q 12h 20 q 12h 20 q 12h 20 q 8h 20 q 8h
Ampicillin 50 q 12h 50 q 8h 50 q 8h 50 q 6h 50 q 6h
Ampicillin/sulb 100–300 div q 6h

Amoxicillin 30 div 25–50 div tid
bid
Amoxi-clav For 875/125
formulations, 45 div bid
Penicillin G IV 50 000 U 75 000 U 50 000 U 50 000 U 50 000 U q 6h
q 12h q 8h q 8h q 6h
Clindamycin 5 q 12h 5 q 8h 5 q 8h 5 q 6h 7.5 q 6h 5–6 q 8h
Vancomycin 40–60 div q 6h
Gent, gentamicin; tobra, tobramycin; sulb, sulbactam; amoxi, amoxicillin, clav,
clavalunate.
Figure 4
(a) Hypertrophic scar of the donor site after harvesting of a
latissimus dorsi flap. (b) Parascapular flap donor area
showing stretching of the scar. (c) The dystrophic aspect of
the donor area of a dorsalis pedis flap, covered with an
inadequate split thickness skin graft.
of failed microsurgical operations is rather higher in infancy because of the wide

indications for operation (Canales et al 1991).
Scar retraction and hypertrophy in both the traumatized areas and the donor areas have
been observed (Fig. 4). As already emphasized, these cause aesthetic and functional
problems for they interfere with tissue sliding and range of articular motion. Moreover a
scar may induce secondary alterations during the growth of the limb. An adequate
planning of the incision is mandatory and a more limited skin paddle should be
considered whenever a large composite musculo- or fasciocutaneous flap is required.
Pressure garments and silicone tapes should be used to reduce the tendency of scars to
hypertrophy.
Infections are less frequent than in adults (Canales et al 1991). The better perfusion of
tissues and the immunological status of children are favourable factors in preventing
bacterial growth and make it possible to eradicate the infecting agent with greater ease
Conversely, septic damage to the growing structures is responsible for severe secondary
deformities and length discrepancies.
Conclusions
Reconstructive surgery for severe post-traumatic defects of the upper limb has broad
indications in children, considering the greater lifespan and good long-term results
characterized by a better functional recovery.
The technical knowledge required for the treatment of paediatric lesions is not
substantially different from that for microsurgery in adult patients. Nevertheless,
paediatric surgery based on a specific knowledge of the peculiar characteristics of the
young patient leads to better patient care and to a more suitable choice of reconstructive
procedures in terms of functional and aesthetic results.
An injured child requires an organized team approach for the best possible care.
Anaesthesiological requirements, for instance, do not end with surgery, but continue into
the postoperative period for long-term control of pain and anxiety, given the close link
between these two factors and limb perfusion. To accomplish this, physicians from all
specialties must cooperate and be knowledgeable about the up-to-date paediatric
treatment techniques.
References
American Academy of Pediatrics (2000) Bites. In: Pickering LK, ed. Red Book: Report of
the Committee of Infectious Diseases, 2 5th edn. Elk Grove Village, Illinois, 155–9.
Banic A, Wulf K (1986) Latissimus dorsi free flaps for total repair of extensive lower leg
injuries in children, Plast Reconstr Surg 79:769.
Becker C, Gilbert A (1990) Lambeau antébrachial des branches distales de I’artère
cubitale. In: Gilbert A, Masquelet AC, Hentz RV, eds. Les Lambeaux Artériels
Pédiculées du Membre Supérieur. Expansion Scientifique Francaise: Paris.
Behrens FF (1998) Fractures with soft tissue injuries. In: Green NE, Swiontkowsky MS,
eds. Skeletal Trauma in Children, vol 3, 2nd edn. WB Saunders: Philadelphia, 103–19.
Bell LM, Baker MD, Beatty D et al (1992) Infections in severely traumatized children, J
Pediatr Surg 27: 1394–8.
Birch R, Achan P (2000) Peripheral nerve repairs and their results in children, Hand Clin
16:579–95.
Canales F, Lineaweaver WC, Furnas H et al (1991) Microvascular tissue transfer in
paediatric patients: analysis of 106 cases, Br J Plast Surg 44:423–7.
Ceruso M et al (2000) Elbow joint reconstruction with a vascularized
metatarsophalangeal joint transfer from the great toe. VII Congress of the FESSH:
Barcelona, Spain, 21–24 June.
Fagelman MF, Epps HR, Rang M (2002) Mangled extremity severity score in children, J
Pediatr Orthop 22:182–4.
Fried G, Salerno T et al (1978) Management of extremity with combined neurovascular

and muscoloskeletal trauma, J Trauma 18:481–6.
Gilbert A, Mathoulin C (2000) Vascularized bone grafts in children. Specifics and
indications, Ann Chir Plast Esthet 45:309–22.
Holmes MJ, Reyes HM (1984) A critical review of urban pediatric trauma, J Trauma
24:253–5.
Innocenti M, Ceruso M, Manfrini M et al (1998) Free vascularized growth-plate transfer
after bone tumor resection in children, J Reconstr Microsurg 14:137–43.
Iwaya T, Harii K, Yamada A et al (1982) Microvascular free flaps for the treatment of
avulsion injuries of the feet in children, J Trauma 22:15.
Mazurek A (1991) Pediatric trauma: overview of the problem, J Post Anesthiol Nurs
6:331–5.
McCann ME, Kain ZN (2001) The management of preoperative anxiety in children: an
update, Anesth Analg 93:98–105.
Mollit DL (2002) Infection control: avoid the inevitable, Surg Clin North Am 82:365–78.
Moulton S (2000) Early management of the child with multiple injuries, Clin Orthop Rel
Res 376:6–14.
Parry SW, Toth BA, Elliot LF (1998) Microvascular freetissue transfer in children, Plast
Paul O, Jouglet T, Camboulives J (1997) Les traumatismes severes de I’enfant, Arch
Pediatr 4:443–59.
Raimondi PL, Petrolati M, Delaria G (2000) Replantation of large segments in children,
Ramenofsky ML, Moulton SL (1995) The pediatric trauma center, Semin Pediatr Surg
4:128–34.
Romaña C, Goubier JN, Gilbert A, Masquelet AC (2000) Coverage of large skin defects
of the pediatric upper extremity, Hand Clin 16:563–71.
Seddon HJ (1975) Results of repairs of nerves. In: Surgical Disorders of Peripheral
Nerves, 2nd edn. Churchill Livingstone: Edinburgh, 312.
Shapiro J, Akbarnia BA, Hanel DP (1989) Free tissue transfer in children, J Pediatr
Orthop 9:590–5.
Stevenson JH, Zucker RM (1986) Upper limb motor and sensory recovery after multiple
proximal nerve injury in children: a long term review of five patients, Br J Plast Surg
39:109–13.
Taylor GI, Wilson KR, Rees MD et al (1988) The anterior tibial vessels and their role in
epiphyseal and diaphyseal transfer of the fibula: experimental study and clinical
applications, Br J Plast Surg 41:451–69.
Tsai TM, Ludwig L, Tonkin M (1986) Vascularized fibular epiphyseal transfer, Clin
Orthop 210:228–34.
Urbaniak JR, Foster JS (1992) Reimplantation in children. In: Microsurgical Procedures.
Churchill Livingstone.
Weinberg A, Mosheiff R et al (1999) Amputated lower limbs as a bank of organs for
other organ salvage, Injury 30(Suppl 2):B34–8.
Yücel A, Aydin Y, Yazar S, Altintas F, Senyuva C (2001) Elective free-tissue transfer in
pediatric patients, J Reconstr Microsurg 17:27–36.
25
Future advances in hand and upper limb
surgery: application of tissue engineering
and biotechnology
Panayotis N Soucacos
Introduction
Advances in the fields of biotechnology and tissue engineering offer new possibilities in
the repair or regeneration of tissue loss in disease or injury. Although biotechnology and
tissue engineering have broad applications in several medical disciplines, a major portion
of the research effort has focused on applications in orthopedics with emphasis on the
development of techniques for developing bone, articular cartilage, ligaments, tendons
and nerves.
Biotechnology and tissue engineering represent a multidisciplinary approach to
solving some of the most demanding medical problems, particularly the creation of new
tissues similar to those in the living organism. These technical approaches include
strategies using new synthetic polymer formulations, biologic constructs as well as
various alternatives in tissue regeneration. This chapter will examine the fundamental
issues of tissue engineering, such as scaffold formation, cell cultures and cell signals. The
possible impact of bimolecular medicine in areas critical to the future of hand surgery,
including tissue replacement, tissue regeneration, wound healing, and bone, tendon,
cartilage, ligament and nerve repair will be discussed.
Tissue replacement and tissue regeneration
In the past, orthopaedic surgeons have been applying the principles of tissue engineering
clinically in tendon and bone transplantation. In these procedures, a scaffold (tendon
(collagen) or bone) is inserted for structural support with or without living cells in
recipient graft sites which have been prepared to promote remodelling and tissue
restoration.
An autograft is the best option for replacing defects, but the problem of donor site
defects (structural or functional) in the host has never been overcome. Although the
development of immune suppressing agents expanded the allograft era, the number of
donors with perfectly matching recipient HLA (human leucocyte antigen) is still limited.
As a result of these inherent difficulties, the possibility of replacing tissue defects with
biochemically functioning materials instead of auto- or allografts has been the focus of
recent investigations. The ultimate goal is to regenerate normal tissue. Bone under most
conditions is capable of regeneration; however, tissues such as tendon, cartilage and
ligament repair themselves with organized scar tissue. Thus, for these tissue types
Future advances in hand and upper limb surgery 401
strategies have been developed to modify normal tissue repair with scar formation to the
regeneration of normal tissue.
With the recent progress in the new technologies of cell modulation, extracellular
matrix fabrication and synthesis of polymers that mimic body structures, self-
regeneration of body defects by host tissue cannot be considered a possibility.
Conventionally, tissue replacement focused on the use of non-biologic and nonviable
materials, such as metals, ceramics and synthetic polymers. Restoration of defects was
usually limited to re-establishing support for mechanical functions of the skeletal and
circulatory systems or to the replacement of morpho-logical defects with bioinert
materials. Recently, research focusing on constructing artificial tissues by combining
modulated cells with extracellular matrix-hybridized synthetic polymers has produced
exciting results with biologically functioning artificial tissues (Suh 2000).
The increase in knowledge of cell biology and embryology has slowly shifted the
focus from tissue restoration to tissue regeneration or generation of site-specific normal
tissue as it occurs in embryonic development. Embryonic tissue is characterized by a high
concentration of pluripotent and progenitor cells and relatively little matrix. Embryonic
and mesenchymal stem cells have become attractive resources because of the potential
for differentiation into various tissue types in response to signal transduction mediated by
various circulating chemical factors such as cytokines (Suh 2000). Embryonic
pluripotential stem cells and adult human stem cells have the potential to differentiate
into various cells types (Thomason et al 1998, Pittenger et al 1999).
Components of tissue engineering
All tissues consist of cells, extracellular matrix and ionic body fluid. The extracellular
matrix plays a fundamental role in providing a suitable living environment for cells and
in maintaining the tissue’s structure. By hybridizing the extracellular matrix with
polymers, cultured cells can then be introduced, resulting in a biomimicking material
with biological properties appropriate for tissue replacement. Thus, three essential
components are required for tissue engineering:
• scaffold or matrix
• cells
• cellular signals in the form of growth factors or transfected genes.
The scaffold or matrix

A scaffold or matrix that provides a construct for the cells to grow in is a crucial
component of tissue engineering. A scaffold can be an artificial construct of polymers.
Human tissues are comprised of biologically and structurally complex acellular fabrics
that provide a supportive scaffold or matrix for cellular growth and have biologically
important chemical properties that profoundly affect cell growth and differentiation.
Initially, the scaffolds or matrices were developed from biodegradable polymers which
supported the initial growth and differentiation of cells. These, however, had inherent
properties that allowed them to degrade over time, thus allowing the cells themselves to
produce the matrix components specific to that particular tissue. Amongst the new
polymers developed, polyactic acid, polyglycolic acid and polypropyl fumarate have
exhibited not only novel biomechanical properties, but, in particular, the ability to
promote growth of tissue. As our awareness of the extracellular matrix constituents
increases, more tissue-specific scaffolds can be developed. An important future direction
in the development of new scaffolds includes the incorporation of cellular signals that
enhance cell growth and differentiation.
The cells
Although tissues are complex structures comprised of various cell types, most
investigators in tissue engineering have used only fully differentiated cells, such as
osteoblasts, chondrocytes or others. For example, skin is composed of multiple
differentiated cell populations including keratinocytes, melanocytes, neural cells,
fibroblasts, adipocytes, smooth muscle cells, endothelial cells, etc. To engineer an
anatomically precise tissue would entail the use of numerous differentiated cell types
such as those described for skin. In light of the knowledge that new cells in any tissue
differentiate from a quiescent population of stem cells, which are responsible for
maintaining the long-term integrity of the tissue, research has recently focused on cells
that are undifferentiated (Solter and Gearhart 1999). The advantage of using stem cells is
that they can differentiate into individual specific cell types and also reproduce
themselves so as to maintain the population of stem cells. Recently, investigators have
proposed methods to obtain autologous stem cells, embryonic stem cells or cloning
(Pennisi 1997, Ferber 1999).
The cellular signals

The regulation of cellular processes that occurs during tissue repair is complex, and
growth factors and cytokines play a central role. Advances in molecular biology have
given us a clearer picture of how growth factors influence repair through receptor
activation, signal transduction and changes in target gene expression. These, in turn, alter
cell proliferation, migration, as well as other cellular metabolic activities. It is very likely
that during the twenty-first century new treatment paradigms will entail adding or
subtracting growth factors to ultimately induce changes in cell function.
Various growth factors have a prominent role in the regulation of wound healing
(Breuing et al 1997). They are released predominantly by various activated cells at the
wound site. Recently, healing rates in normal wounds were found to be accelerated by
adding exogenous TGF (transforming growth factor)-beta, PDGF (platelet derived
growth factor), IGF (insulin-like growth factor)-1, or FDF-2 (Cromack et al 1990). In
addition, these growth factors also augment repair in organisms with impaired wound
healing conditions, for example chronic steroid use or diabetes (Cromack et al 1991).
Biomaterials
Several important requirements must be adhered to in the development of biomaterials

for orthopaedic applications. These include biocompatibility, appropriate mechanical
properties, promotion of tissue formation, ease of material sterilization, as well as ease of

handling. It is important that any biomaterial used in hand surgery must be
biocompatible. In other words, the material must not elicit extreme immunogenic or
cytotoxic responses. Because most of these materials are designed to degrade in vivo, it is
also important that the degradation products are biocompatible (Thomson et al 1995).
The initial mechanical properties of a biomaterial that is implanted must be as close as
possible to those of the tissue that is to regenerate. Appropriate mechanical properties
ensure proper support in early healing stages, as well as a graded load transfer later in the
process during the creation of replacement tissue that is identical to the original (Yaszeski
et al 1996). Several mechanical properties need to be considered for materials to be used
in orthopaedics, including compression, tension and torsion. In general compressive
properties are an important consideration for cancellous bone, while tensile properties are
important for cortical bone. Properties such as amount of void space and degradation time
are selected to encourage tissue growth and vascularization within the material (Thomson
et al 1995). It should be relatively easy to sterilize the biomaterial to help prevent
infection (Yaszeski et al 1996) and it should be easy to handle (Temenoff and Mikos
2000).
Bone
In the past, bone tissue engineering has focused primarily on repairing bony defects with
polymeric materials and ceramics. Ceramics, such as calcium phosphate hydraulic
cement, have often been selected to aid fracture fixation and filling of bony defects, as
they promote bony ingrowth, are biocompatible and harden in situ (Ikenga et al 1998).
Despite considerable focus on cements that are quickly resorbed, many existing calcium
phosphate materials degrade relatively slowly, which can lead to decreased bone
regeneration at the site of the implant (Frankenburg et al 1998). While these cements
show good biocompatibility and perform well in compression, tensile strengths are still
below that of natural bone (Constanz et al 1995, Frankenburg et al 1998). In an effort to
address these concerns, researchers have focused on polymeric materials.
Polymers are injectable and harden in situ. Although polymers may be less
biocompatible and more difficult to sterilize than ceramic cements, mechanical properties
and degradation times are more easily tailored, giving them several distinct advantages
for use in orthopaedic surgery. A promising candidate for clinical application is
poly(propylene fumarate) (PPF) which shows versatility and excellent mechanical
properties (Temenoff and Mikos 2000).
The ultimate mechanical properties of PPF can vary greatly according to the method
of synthesis and the cross-linking agents used in its formulation. Its degradation time is
dependent on polymer structure and other components that comprise the composite
material. Although initially a mild inflammatory response is observed and a fibrous
capsule formed around the implant, PPF does not exhibit a deleterious longterm
inflammatory response when implanted subcutaneously in rats (Peter et al 1998). Recent
in vitro studies have shown that the PPF/betaTCP construct has significant
osteoconductive properties. In addition, these studies indicated that the composite
encourages attachment, proliferation and differentiation of osteoblastic functions of rat
marrow stromal cells (Peter et al 2000). Moreover, recent studies indicate that the initial
mechanical properties can be improved significantly by directing cell migration and
differentiation within the material with the use of growth factors, for example TGF-beta 1
(Lu et al 2000).
The periosteum has osteogenic properties through the release of periosteum-derived
osteoblasts. As a result, several investigators have attempted to use periosteum to
generate bone. Periosteal grafts have been successfully applied to induce new bone
formation, with vascularized periosteum showing a constant or even increasing level of
osteogenic capacity over time (Ritsila et al 1972, Ishida et al 1996). Bone formation by
endochondral ossification can be induced when periosteum is placed directly onto a
polyglycolic acid polymer, resulting in the migration of the periosteal cells from the
tissue and their attachment and spreading on the polymer (Isogali et al 1999).
Cartilage
The principles and requirements of cartilage tissue engineering differ significantly from
those of bone tissue engineering. The biomaterials used for cartilage engineering are, like
bone, required to withstand compressive loads. However, cartilage must provide
frictionless movement at the joints. Thus, important considerations for appropriate
cartilage biomaterials include the ability to withstand shear forces at the joint surface.
Both naturally derived and synthetic polymers have been used in cartilage repair with
notable differences in their biocompatibility and in their ability to promote tissue
formation. Transplanted chondrocytes on a polyglycolic acid polymer mesh have been
shown to regenerate cartilage (Vacanti et al 1991).
Of the naturally derived polymers, fibrin glues and alginate gels have been widely
studied for injectable cartilage applications. Several investigators have explored the
application of a degradable fibrin mesh produced by injecting fibrinogen and thrombin as
a scaffold for chondrocytes (Sims et al 1998). The advantage of this method is that the
patient’s own fibrinogen and thrombin can be used, thus eliminating concerns about
biocompatibility, sterility and temperature changes during setting. Recent experiments
show that when the cell-fibrinogen-thrombin mixture was injected into defects, a hyaline-
like cartilage was formed with more glycosaminoglycan and type II collagen than in
untreated defects (Hendrickson et al 1994).
Alginate is a liquid derivative of seaweed that can be cross-linked with calcium and
injected into the cartilaginous defect. Histologic evaluation showed the architecture of the
newly formed tissue induced by alginate to be similar to that of the native cartilage.
However, there was little evidence of degradation of the alginate biomaterial. There was
also some evidence that it may be immunogenic (Paige et al 1996).
Tendons
Tendon defects are a major concern in hand surgery because of the limited availability of
appropriate tissue sources for tendon grafting. In many cases, unfavourable results can be
attributed to the lack of ideal graft material, rather than the surgical technique used.
Although autografts are considered ideal for repairing tendon defects, there are limited
donor sites and harvesting an autologous tendon often leads to minor functional
disabilities at the donor site. On the other hand, tendon allografts are generally unsuitable
because of immune rejections. Most prosthetic replacements (e.g. carbon fibres, silastic
sheets, Dacron grafts, etc.) fail to achieve satisfactory long-term results, as they are
unable to heal properly with the tendon tissue and they are unable to sustain the
mechanical forces required for normal movement (Milthorpe 1994).
Compared to other tissue types such as bone and cartilage, tendon engineering has not
been studied extensively. To date several studies have tested the feasibility of engineering
tendon tissues with autologous tenocytes to bridge the tendon defects (Cao et al 1994,
2002, Young et al 1998, Awad et al 1999). One of the pioneer experiments in tendon
engineering was performed in nude mice. The results demonstrated for the first time that
tendon tissue could be engineered using polyglycolic acid fibres seeded with tenocytes
(Cao et al 1994). However, because an immunodeficient animal model was used, there
was no information forthcoming regarding the biocompatibility of polyglycolic acid with
host tissues and seed cells. In addition, this study did not address the effects of
mechanical loading on the engineered tendons. More recently, the same research team
presented results of experiments using a hen model and nicely demonstrated that tendon
tissue could be engineered in vivo to bridge the tendon defect (Cao et al 2002).
Moreover, their findings showed that the engineered tendons resembled natural tendons
in their gross appearance (structure, colour and texture), and their histologic structure was
also similar to that of natural tendons as regards collagen bundle alignment and cell-to-
collagen ratio. Unlike their earlier study, the hen model study also assessed the
mechanical properties of the in vivo formed tendon. An important finding was that the
strength of the engineered tendons was about 83% of the normal tendon breaking
strength. Moreover, the engineered tendon appeared to gain tensile strength gradually
over the entire period of tissue construction, indicating similar biomechanical properties
to natural tendons (Cao et al 2002).
Two research teams have investigated the effectiveness of mixing bone marrow
stromal cells with collagen gel to repair tendon defects in a rabbit model (Young et al
1998, Awad et al 1999). Although the biomechanical properties were improved when
compared to the control tissue, the engineered tissues did not display a histologic
structure similar to that of normal tendons.
Critical evaluation of the results of these studies underscores two fundamental
elements in tissue engineering: the biomaterial applied and the seed cell. The biomaterial
applied as the scaffold material used is of primary importance. In the hen model, the
scaffold material used consisted of unwoven polyglycolic acid fibres which otherwise are
unable to sustain any tension. To provide additional mechanical strength, the
investigators wrapped the fibres with a biomembrane of intestinal submucosa, and
allowed the severed ends to retract to a set degree to avoid overloading.
The seed cell is the second key element. In the study by Cao et al (2002) tenocytes
were selected as seed cells to engineer the tendon tissue. The disadvantage of using
tenocytes for tendon construction is the need to harvest autologous tendon tissue, which
may not be practical clinically. Moreover, tenocytes from other mammalian sources (e.g.
pigs) are difficult to culture and grow. Thus, it becomes clear that a remaining important
step for the future success of tendon engineering is the ability to identify an alternative
source of seed cells, such as dermal fibroblasts.
A common clinical problem is adhesion of the repaired tendon to surrounding tissues.
Generally, it is believed that preservation of paratenon tissue helps reduce adhesion. The
tendons engineered in these studies were not surrounded by paratenon, and therefore
adhered strongly to the surrounding tissues. In this regard, future studies must also focus
on means of engineering a composite tendon tissue that includes a paratenon.
In the past few years, several groups have been interested in applying methods of cell
culture and molecular biology to flexor tendon research. Banes and colleagues (1988)
developed a method to separate and propagate chicken fibroblast/tenocyte populations
from the synovium (epitenon) and the internal tendon. It is also apparent that a third cell
line composed of fibroblasts derived from the surrounding tendon sheath can be cultured.
Growth factors, such as TGF-beta 1, have been implicated in the process of tendon
wound healing.
Vessels
Polyvinylchloride (PVC) was first used to restore dissected vessels in 1952. Since then,
synthetic polymers have been regarded as one of the most important biomaterials, mostly
because of their malleable chemical and physical characteristics. To protect against the
formation of thrombosis from blood plasma proteins adhering to the polymer surface of
the artificial blood vessels, chemical modifications of the lumen with hydrophilic-
hydrophobic phase segregation or grafting protein repellant on the polymer surface have
been attempted with encouraging results (Wesolowski et al 1963, Lee et al 1999).
Neovascularization appears to be dependent on both angiogenesis and increased
vascular permeability (Berse et al 1992). Both of these processes are endogenously
stimulated by vascular endothelial growth factor (VEGF) (Zhang et al 2001). VEGF is
produced by a variety of different cells in the human body and its receptors are found on
endothelial cells (Berse et al 1992). VEGF sets off a cascade of events which lead to
increased vascular permeability. This in turn, stimulates the migration of endothelial cells
through the extracellular matrix. By effecting these two processes, VEGF is believed to
improve angiogenesis (Taub et al 1999).
Nerves
Current issues in peripheral nerve surgery include improvement of regeneration and

creation of alternative sources of donor nerves. Several advances have been made in the
surgical technique, including introduction of end-toside neurorrhaphy and baby-sitter
nerve anastomoses (Zhang et al 2000). Biotechnological advances include
allotransplantation of nerves, growth factors and artificial nerve conduits (Malizos et al
1997).
Nerve allografts or xenografts are considered a good alternative for nerve conduits if
immunosuppression is found to be safe and efficacious. Nerve allotransplantation has
already been performed in patients with adequate sensory reinnervation (Mackinnon et al
1992). Neurotrophic factors play an important role in nerve regeneration and as a result,
there is great clinical interest in addressing whether they can supplement damaged nerve
and nerve repairs to enhance sensory or motor recovery, or alternatively to avoid
excessive tissue inflammation and scarring.
Tissue engineering of peripheral nerves has focused on means to create either natural
or synthetic tubular nerve guidance channels as alternatives to nerve autografts. The
various options for guidance channels include synthetic substances, such as lactate
polymer, polyglactin mesh, polyethylene, silicone and siliconepolymer tubes, as well as
biologic conduits including autologous collagen, arterial grafts, veins and acellular
muscle grafts (Fansa et al 1999). These are selected for their ability to help direct axon
sprouting from the regenerating nerve end, to provide a conduit for diffusion of
neurotropic and neurotrophic factors secreted by the damaged nerve stumps and
minimize infiltration of fibrous tissue (Hudson et al 2000).
Good axonal regeneration has been observed with the use of autologous vein grafts,
and vein conduits have been used clinically to bridge short digital nerve gaps (Malizos et
al 1997, Strauch et al 1997). Acellular muscle has been used for the repair of digital
nerves, but because of the lack of viable Schwann cells there was failure of regeneration
(Fawcett and Keynes 1986).
As Schwann cells play a crucial role in regeneration of peripheral nerves due to their
neurotrophic and neurotropic influence (Bunge 1993), recent studies have been aimed at
evaluating the possibility of creating tissue engineered nerve grafts from biologic
matrices combined with viable Schwann cells (Fansa et al 2001). Schwann cells produce
and accumulate trophic factors for regenerating axons and thus are essential for axonal
regeneration, particularly for long gaps (Ide 1996). Schwann cells produce basal lamina
components, such as collagen type IV, which provide the extracellular matrix for
attachment of the regenerating axons. More importantly, the Schwann cells form a
column of cells, the band of Bungner, within the basal lamina tube after wallerian
degeneration has taken place. This cell column serves as the pathway for the regenerating
axons to reach their target (Gulati et al 1995). Recent studies have found several
advantages of the application of acellular muscle in combination with cultured Schwann
cells for nerve regeneration. This combination provides the advantage of large basal
lamina tubes which can serve as pathways for the regenerating axons and the necessary
effects of viable Schwann cells (production and accumulation of neurotrophic and
neurotropic factors) to support early axonal regeneration (Fansa et al 2001).
Conclusions
Biotechnology and tissue engineering represent a multidisciplinary approach to solving

some of the most demanding medical problems, particularly the creation of new tissues
similar to those in the living organism. These new technical approaches include strategies
using new synthetic polymer formulations, biologic constructs as well as various
alternatives in tissue regeneration. Fundamental issues in tissue engineering include
scaffold formation, cell cultures and cell signals. The application of tissue engineering
techniques in areas critical to the future of hand surgery, including tissue replacement,
tissue regeneration, and bone, tendon, cartilage, ligament and nerve repair has met with
promising results. Today, cell transplantation on artificial matrices is rapidly being

applied successfully to form several specific tissue types (bone, cartilage, tendon, nerve,
etc.). On the other hand, the construction of anatomical units, such as an entire joint,
present special challenges in tissue engineering. These anatomical units are composed of
multiple cell–tissue types, each with its tissue-specific extracellular matrices. The next
challenge in biotechnology and tissue engineering will be to combine the formation of
several musculoskeletal tissue components into a functional anatomical unit. Recent
studies have presented the application of three different cell types (periosteum, cartilage
and tendon) to form an entire phalangeal joint with a predetermined shape and
composition (Isogali et al 1999).
References
Awad HA, Butler DI, Boivin GP et al (1999) Autologous mesenchymal stem cell-
mediated repair of tendon, Tissue Eng 5:267.
Banes AJ, Donlon K, Link GW et al (1988) Cell populations of tendon: a simplified
method for isolation of synovial cells and internal fibroblasts. Confirmation of origin
and biologic properties, J Orthop Res 6:83.
Berse B, Brown LF, Van der Water L, Dvorak HF, Senger DR (1992) Vascular
permeability factor (vascular endothelial growth factor) gene is expressed
differentially in normal tissues, macrophages, and tumors, Mol Biol Cell 3:211.
Brueing K, Andrec C, Helo G et al (1997) Growth factors in the repair of partial
thickness porcine skin wounds, Plast Reconstr Surg 100:657.
Bunge RP (1993) Expanding roles for the Schwann cell: ensheathment, myelination,
tropism and regeneration, Curr Opin Neurobiol 3:805.
Cao Y, Vacanti JP, Ma X et al (1994) Generation of neotendon using synthetic polymers
seeded with tenocytes. Transplant Proc 26:3390.
Cao Y, Yongtao I, Liu W, Shan Q, Buonocore SD, Cui L (2002) Bridging tendon defects
using autologous tenocyte engineered tendon in a hen model, Plastic Reconstr Surg
110:1280–9.
Constanaz BR, Ison IC, Fulmer MT et al (1995) Skeletal repair by in situ formation of the
mineral phase of bone, Science 267:1796–9.
Cromack DT, Porras-Reyes B, Mustoe TA (1990) Current concepts in wound healing:
growth factor and macrophage interaction, J Trauma 30S:129.
Cromack DT, Pierce GF, Mustoc TA (1991) TGF-beta and PDGF mediated tissue repair:
identifying mechanisms of action using impaired and normal models of wound
healing, Prog Clin Biol Res 365:359.
Fansa H, Keilhoff G, Wolf G, Schneider W (2001) Tissue engineering of peripheral
nerves: a comparison of venous and acellular muscle grafts with cultured Schwann
cells, Plast Reconstr Surg 107: 485–94.
Fawcett JW, Keynew RJ (1986) Muscle basal lamina: a new graft material for peripheral
nerve repair, J Neurosurg 65:354.
Ferber D (1999) From the lab to the clinic, Science 284:423.
Frankenburg EP, Goldstein SA, Bauer TW, Harris SA, Poser RD (1998) Biomechanical
and histological evaluation of calcium phosphate cement, J Bone Joint Surg
80A:1112–24.
Gulati AK, Rai DR, Ali AM (1993) Influence of cultured Schwann cells on regeneration
through acellular basal lamina grafts, Brain Res 705:118.
Hendrickson DA, Nixon AJ, Grande DA, Todhunter RJ, Minor RM, Erb H, Lust G
(1994) Chondrocyte-fibrin matrix transplants for resurfacing extensive articular
cartilage defects, J Orthop Res 12:485–97.
Hudson TW, Evans GR, Schmidt CE (2000) Engineering strategies for peripheral nerve
repair, Orthop Clin North Am 31:485–98.
Ide C (1996) Peripheral nerve regeneration, Neurosci Res 25:101.
Ikenaga M, Hardouin P, Lemaire J, Andrianjatovo H, Flautre B (1998) Biomechanical
characterization of a biodegradable calcium phosphate hydraulic cement: a
comparison with porous biphasic calcium phosphate ceramics I, J Biomed Mater Res
40:139–44.
Ishida H, Tamai S, Yajima H, Inoue K, Ohgushi H, Dohi Y (1996) Histologic and
biochemical analysis of osteogenic capacity of vascularized periosteum, Plast
Isogali N, Landis W, Kim H et al (1999) Formation of phalanges and small joints by
tissue-engineering, J Bone Joint Surg 81A:306–16.
Lee J, Lee D, Suh H, Park DK, Kim YH, Park J (1999) Complement functional activity
of PEG modified polyurethane films with different end groups, Biomater Res 3:103–6.
Lu I, Stamatas GN, Mikos AG (2000) Controlled release of transforming growth factor-
β1 from biodegradable polymers, J Biomed Mater Res 50:440–56.
Mackinnon SE, Hudson AR (1992) Clinical application of peripheral nerve
transplantation, Plast Reconstr Surg 90:695.
Malizos KN, Dailiana ZH, Anastasiou EA, Sarmas I, Soucacos PN (1997) Neuromas and
gaps of sensory nerves of the hand: management using vein conduits, Am J Orthop
24:481–5.
Milthorpe BK (1994) Xenografts for tendon and ligament repair. Biomaterials 15:745.
Paige KT, Cima LG, Yaremchuk MJ, Schloo BI, Vacanti JP, Vacanti CAQ (1996) De
novo cartilage generation using calcium alginate-chondrocyte constructs, Plast
Pennisi E (1997) Cloning: the lamb that roared, Science 278:2038.
Peter SJ, Miller ST, Zhu G, Yasko AW, Mikos AG (1998) In vivo degradation of
poly(propylene fumarate)/ β-tricalcium phosphate injectable composite scaffold, J
Biomed Mater Res 41:1–7.
Peter SJ, Lu I, Kim DJ, Mikos AG (2000) Marrow stromal osteoblast function on a
poly(propylene fumarate)/β-tricalcium phosphate biodegradable orthopedic composite,
Pittenger MF, Mackay AM, Beck SC et al (1999) Multilineage potential of adult human
mesenchymal stem cells, Science 284:143–6.
Ritsila V, Alhopuro S, Rintala A (1972) Bone formation with free periosteum. An
experimental study, Scand J Plast Reconstr Surg 6:51–6.
Sims CD, Butler PEM, Cao YL et al (1998) Tissue engineered neocartilage using plasma
derived polymer substrates and chondroytes, Plast Reconstr Surg 101:1580–5.
Solter D, Gearhart J (1999) Enhanced: putting stem cells to work, Science 283:1468.
Strauch B, Ferder M, Lovell-Allen S, More K, Kim DJ, Llena J (1997) Determining the
maximum length of a vein conduit used as an interposition graft for nerve
regeneration, J Reconstr Microsurg 8:605.
Taub PJ, Silver L, Weinberg H (2000) Plastic surgical perspectives on vascular
endothelial growth factor as gene therapy for angiogenesis, Plast Reconstr Surg
105:1034–42.
Thomason JA, Itskovitz-Eldor J, Shapiro SS et al (1998) Embryonic stem cell lines
derived from human blastocysts, Science 282:1145–7.
Thomson RC, Wake MC, Yaszemski MJ, Mikos AG (1995) Biodegradable polymer
scaffolds to regenerate organs, Adv Polym Sci 122:245–74.
Vacanti CA, Langer R, Schloo B, Vacanti JP (1991) Synthetic polymers seeded with
chondrocytes provide a template for new cartilage formation, Plast Reconstr Surg
88:753–9.
Wesolowski SA, Fries CC, Domingo RT, Liebig WJ, Sawyer PH (1963) The compound
prosthetic vascular graft: a pathologic survey, Surgery 53:19–44.
Yaszemski MJ, Payne RG, Hayes WC, Langer R, Migos AG (1996a) Evolution of bone
transplantation: molecular, cellular and tissue strategies to engineer human bone,
Yaszemski MJ, Payne RG, Hayes WC, Langer R, Mikos AG (1996b) In vitro degradation
of a poly(propylene fumarate) based composite material. Biomaterials 17:2127–30.
Young RG, Butler DL, Weber W, Caplan AI, Gordon SL, Find DJ (1998) Use of
mesenchymal stem cells in a collagen matrix for Achilles tendon repair, J Orthop Res
16:406.
Zhang Z, Soucacos PN, Beris AE, Bo J, Ioachim E, Johnson EO (2000) Long-term
evaluation of rat peripheral nerve repair with the method of end-to-side neurorrhaphy,
J Reconstr Microsurg 16:303–11.
Zhang F, Fischer K, Komorowska-Timek E et al (2001) Improvement of skin paddle
survival by application of vascular endothelial growth factor in a rat TRAM flap
model, Ann Plast Surg 46:314–19.
Index
A
A2-A4 pulley extensor 192–3
abdominal hernia, through defect iliac wing, after bone removal 63
active extension of toes, normal range, EDB provided 211
acute compartment syndrome 269
acute flaps, definition 51
adductorplasty 269, 271
adipofascial radial forearm flap 7–8
procedure stages 8
adipofascial turnover flap 204
aggressive giant cell tumor of distal radius, proximal carpal row invasion 81, 84
AH (abductor hallucis) 266–7
harvesting operative picture 267–8
myocutaneous free flap, harvest 267–8
transfer, type 2 thenar injury 268
alginate conduits 160–1
Allen tests 230, 262
long term vascular results 145
permeability confirmation, radial artery 13, 16
allogeneic arthroplasty 110
allograft bone transplantation, bone reaction types 109
allograft nerve grafting, pre-treatment 147
allografts 60–2, 64–5, 113
allovascularized transplantation, indications and improved successes 235–6
anaesthetic considerations, in children, as difficult and specialist skill 304–5
antebrachial flaps, issues of choice 16
anterior bone graft donor sites, complications 70
anterior interossoeus nerve 255
anterior surface of elbow reconstruction, recurrent radial flap, procedure stages 10–11
anterolateral thigh fascial flap harvested free 265
results after 3 months 265
antibiotic (examples), paediatric doses 309–10
antibiotic treatment 299–300
APB (abductor pollicis brevis) tendon 268
arm see autogenous
reconstruction, humerus
arthrodesis, see also joint fusion
arthrodesis of the elbow
amputation-reimplantation 130
and shortening of the upper limb 283
arthrodesis of shoulder
ideal position 126
joint fusion 126–9
methods 127
plate and screws, radiograph 128
position 128
pre-requisite conditions 126
arthrodesis of wrist 130–2
Index 412
author’s method 130–1

complications 131–2
indications 130
main position of 30 degrees and 15 degrees ulnar deviation 131–2
medial approach 131
types 132
using bone graft 69
vascularized peroneal graft, traumatic tumour 131
ATLS (advanced trauma life support) 304
atrophic non-union of humerus, prior gunshot wound, extensive bone loss 80–1
auto- and allografts, combination benefits 65
autogenous bone graft and nail fixation
consolidated humerus 66
delayed union
bone consolidation, absence 66
stable fixation with nail 66
unstable humerus 66
autogenous reconstruction, humerus 65
autogenous transplantation proximal fibula, severe bone loss 69
autograft 59–64, 313
autologous cortical bone grafts, advantages 61
autologous fresh cancellous bone graft
cement spacer removal and radius reconstruction 290
external device replacement by a plate, complete healing at 4 months 290
silicone rod placement, under flap 291
autologous nerve grafts (isografts) 154–5
autologous tendons as graft 160–1
autologous vein grafts 160
avascular necrosis fracture, rotator cuff failure and glenoid deficiency 123
avulsion of the upper limb 278
B
Battiston experimental model, conduit guides for axonal growth 160
bioartificial nerve graft, synthetic material base 157
biocortical cancellous graft from ilium, technique for removal 130–1
biodegradable polymer tubes 156–8
bone auto- and allografts
advantages/disadvantages 69–70
biological properties 59–60
bone allograft and joint prosthesis 68
in post-traumatic reconstruction 59–70
receiver site 59
structural properties 60–1
bone collapse, due to osteoporosis 121
bone defect, infection 77
bone formation induction, extraosseous sites 104
bone free flap 39
bone grafting
applications 64–9
arthrodesis of wrist 69
complications and limitations 69–70
Index 413
followed by coverage with tendinofasciocutaneous composite flaps 283–4

graft choice 61
and shortening 39
sourcing donor site 61–4
bone and joint system reconstruction 291–3
bone marrow, content examples 104
bone morphogenic proteins (BMP) 99–100
bone radionecrosis, non-union associated 77
bone reconstruction 278
procedures 291–2
spacer, functional purposes 94
bone regeneration evidence, closing of gap, with fragments contact 92
bone shortening 278
sphacelus amputation;
anatomical suturing 280–1
bone substitutes 99–104
clinical applications 102–3
clinical experience 101–2
indications and future directions 103–4
bone wax, usage 63
‘boutonierre deformity’ 202
Boyes’ classification 234
grade III and IV finger flexor system, as new technique 228–9
BR, EPL (extensor pollicus longus) transferred 205
BR (brachioradialis) 200
brachial plexus, proximal long standing paralysis 254
brachial plexus injury 279–80
braided suture, synthetic 192
breast reconstruction, successful recovery sensory function, ‘embracing suture’ rectus abdominis
nerve, TRAM flap 178
bridging nerve defects: role of tissue interpositioning 153–61
Brunner technique 236
Bunnell, type of suture 191
burn-crush thenar injury, type (4) 270–1
C
calcium phosphate ceramics, biocompatible and osteoconductive 104
calcium sulphate 100
cancellous transplants 60
cancellous/corticocancellous autografts 39
capitulum reconstruction 67–9
cartilage allografts, allograft bone transplantation, principles and additional differences 109–10
catastrophic events, post-traumatic defects in children 303
cement with gentamicin and clindamicin, spectrum of action 95–7
ceramic hydroxyapatite 100
ceramics 100
chemotherapy 39
chimeric flap principle 205
chondroma, macroporous biphasic calcium ceramic filled 102–3
chondrosarcoma and revascularized fibular autograft, immediate/postoperative by 13 months 79–80
chronic dislocation of joint, partial compensation, by muscles surrounding joint 111
Index 414
chronic osteo-myelitis, following debridement of bone 35

chronic right elbow osteomyelitis and comcomitant brachial plexus palsy, gun shot wound 25–6
Cialit preservation 235
ciproflexacin 300
clindamycin 300
closed fracture, and primary joint replacement option 117–19
cloxacillin 300
collagen fibres 160
collagen tubes 158
combined flexor tendon and skin transfer 231
combined low median-ulnar nerve palsy 269
combined tendon-skin flap 263
compartment syndrome 279
complex injury (upper limb), definition 33
complex tendon-cutaneous defects, soft tissue reconstruction option, free non-vascularized transfer,
long extensor tendon system 245–6
complex tenolysis, ‘running pulley’ introduction 195
composite skin-tendon free flap web of foot
3 months recovery 55
aesthetic flap integration 55
web of foot planning, and result 55
composite tissue transfer upper extremity 241–7
reconstructive strategy 242
compound defect, factors enabling 289
compound defect as secondary procedure, repair principles 287–93
compound dorsalis pedis flap, donor site-after 1 month, exposure and partial necrosis of extensor
hallucis and tarsal bones evidence 264
compound thenar mass losses 266–9
compound tissue transfers, segmental defects 247
compression apparatus ‘hybrid’ 93
removal at 2 months 93
concomitant rheumatoid disease 118
consequent follow-up requirement, reasons with concomitant reconstruction 242
contracted retinacular system 202
contracted retinacular system release 202
contracting muscle transplant, strong finger flexion enablement 176
conventional tendon grafting 183–222
classification of cases
cicatrix category 186
‘good’ category 185–6
joint damage 186
multiple damage 186
nerve damage 186
historical background 183–4
coralline hydroxyapatite 99–100
corrective osteotomy 66
cortical allografts, excellent vascular supply necessity 61
‘creeping substitution, ‘ resorption and apposition 60
crush component, at dorsum of hand, preoperative clinical pictures 222
crush injury
left hand
finger flexing impossibility 211
Index 415
preoperative radiographs 211

tendon sheath, with extensive damage 212
left hand a sequelae 218
follow-up at 1 year 218
intraoperative flexion of little finger 218
passive motion of little finger achieved 218
TATA technique 218
little finger right hand, lesion of flexor profundus, preoperative picture 209
right hand
clinical follow-up at 3 years 210
intraoperative passive range motion 210
silicone road insertion, retinacular system reconstruction by pulleys 210
to hand 69
crush-degloving injury
amputated stump 44
anterior aspect of left forearm 38–9
dorsum of left hand 40
post-surgical appearance 39
cubitus valgus deformity 66
cutaneous coverage of tissue, upper limb trauma 281
cyclosporine 235
D
debridement
non-viable tissues, high voltage injury, web of hand 55
techniques 52
debridement and application of spacer with external fixator 97
defect coverage 297–9
delayed staged reconstruction vs. ‘as early and as complete as possible’ 242
dermo-epidermic graft 13
diaphyseal allografts 39
digital flexion reconstruction, toe-to-finger free flexor tendon transfer 234–5
digital flexion sliding system technique 227–38
digital nerve grafts 145
‘dishwater pus’, pathognomonic liquefactive necrosis 27
distal humerus
and olecranon loss, AP radiograph, elbow 68
reconstruction 94
distal humerus and olecranon loss, AP radiograph, elbow, recovery stages 68
distal interphalangeal (DIP) joint 184
distal phalangeal joint, extension defect of 35 degrees 237–8
distal radius fractures 102
delayed healing, surgical realignment 69
distal radius with a vascularized fibula graft reconstruction, child 7 years 306–7
distal sphacelus/amputation 279
distal ulnar artery island flap see ulnodorsal septocutaneous flap
distally based posterior interosseous island flap, transposition, and procedure stages 34–5
distally based radial forearm flap 293
donor site, iliac crest 70
Doppler fluxometer 16
Doppler tests 230
Index 416
dorsal hand lesion

example 7
post distally pedicled radial forearm flap 7
dorsal pedis myofascial flap 264
dorsalis pedis 37
dorsalis pedis artery, absence as rarity 261–2
dorsalis pedis tendinocutaneous flap 261–2
dorsum of hand
compound tendon loss 261–2
decision making for complex losses 263–5
dorsum lesion, ulnar forearm flap procedure stages 9
dorsum and thenar regions, combined soft tissue and tendon reconstruction 261–9
E
early free flaps, definition 51
ECRB to EDC and EDU to EDC, tendon transfer completion 222
ECRL (extensor carpiraialis longus) 200
EIP (extensor indicis longus) 203
EIP (extensor indicis proprius) 268
EIP (extensor oligitonum communis) 203
elbow joint reconstruction, greater functional problems, in children 307
elbow prosthesis, soft tissue coverage in reconstruction 175
emergency free flaps 39–47
definitions 51
delayed closure 51
delayed primary closure 51
introduction 242
open injuries reconstruction
disadvantages 54
flap choice 54
indications 52–4
timing 51–2
upper limb 51–5
primary closure 51
emergency free tissue transfer, concept 39
emergency reconstruction, principles 277–84
end-to-end cross-face nerve grafting 178
end-to-side neurorrhaphy
alternative reinnervation
long nerve defects 169–78
methods 170
results 170–5
surgical technique 170
clinical cases 171–2
as technique, reliable and clinicallly useful 175–6
enterobacteriaceae 300
epiphyseal transfer 111–12
donor site examples 111
EPL (extensor pollicies longus) 203
reconstruction 204
tendon graft repair 183
Index 417
ERLC reconstruction by tendon graft taken from ERBC 207

escarectomy reconstruction using vessel grafts and tendon spacers and plastic reconstruction 282
etiopathogenesis 303
Ewings sarcoma 111
radionecrosis of humeral diaphysis, radiograph 82
extensive epiphyseo-diaphyseal resection, consequences 114
extensive fibrosis of flexor apparatus 209
intraoperative passive range of motion 210
solicone rod insertion and retinacular system, reconstruction by pulleys 210
extensor hood deficit, reconstruction 202
extensor retinaculum 195
extensor tendon, infection and secondary rupture 220
extensor tendon defects repair 200, 202, 204
secondary reconstruction 204
extensor tendon grafting, late sequelae 205
extensor tendon reconstruction, sagittal bands, non-vascularized flexor tendon grafts from
amputated index 265
extensor tendons zone VI and VII, absent structures, dynamic sonography are usually helpful,
proximal stump location 186
F
fascial and fasciocutaneous flaps 35, 37
fascial flap plus grafting 185
fascicular graft according Narakas 140
fascicular nerve grafting
concept 138
donor nerve 138–9
of median nerve, carpal tunnel level 139–40
fasciocutaneous flap reconstruction, palmar region 284
fasciocutaneous free tissue transfers 37
FCU transfer, finger extension restoration 291
FCW (fleuro carpi wraris) 205
FDB (flexor digitorum brevis) 266–7
FDS (flexor digitorum superficialis) 268
IV, retrieval distal to carpal ligament, ulnar to the palmar fascia, as acting pulley for
oppensplasty 271–2
surgical technique issues 199
FDS (flexor digitorum superficialis) tail 194
FFMT (free flap muscle transfer) 267–9
FFMT (free functioning muscle transplant) 269
fibronectin and laninin grafts 160
fibronectin mats, as conduits 160
fibula graft infection 95
inserted immediately after surgical cleaning 95
fibula (middle) cut, without interruption to vascularization 94
first dorsal metatarsal artery (FDMA) 261–2
first metacarpal bone benign lesion 102–3
first web space, of foot, free tissue transfers 37
fistulography 96
fixation, surgeon’s preference 131
fixed flexion deformity 232
Index 418
FK506 (tacrolimus) and nerve regeneration 148

flap selection
and type A and B defects 242–5
type B defect, compounds soft tissue defect with loss of superficial flexor muscles and 3rd
degree open ulnar fracture 244
and type C defects 245–6
and type D defects 246–7
flex tendon repair
at 2 months favourable outcome 213
flexor apparatus interruption, staged repair 212
silicone rod insertion, with A2-A4 pulleys reconstructed 213
flexor apparatus, extensive fibrosis 209
flexor apparatus lesion 214
intraoperative finding 214
Micrococcus spp. wound contamination, rehabilitation phase 214
preliminary suture between flexor superficialis and flexor profundus 214
staged flexor grafting procedure Paneva-Holevich technique 215
flexor digitorum sublimis, finger 236
flexor digitorum superficialis 268
flexor pollicis, pedicled graft 197
flexor profundus 197, 231
flexor superficialis 231
flexor superficialis finger 197
flexor tendon defects 184–200
prerequisites 184–5
flexor tendon graft in zone III, IV, V 200
flexor tendon graft in zone VII 204–5
flexor tendon graft in zone VIII 205
flexor tendon graft in zones III and IV 203–4
flexor tendon graft in zones V and VI 203–4
flexor tendon grafting 185, 195–6
zone 1-5, area distal to flexor digitorum superficialis (FDS) 185
in Zone II 189
flexor tendon grafting results 199
flexor tendon reconstruction 204–5
two stage technique 218
flow-through fasciocutaneous free flaps, anatomy and dynamic concepts, in replantation 43
flow-through fasciocutaneous radial flap, marking 44
flow-through flaps, advantages 54
flow-through free fasciocutaneous flap, as single stage technique 44
flow-through free flap concept, as method of choice 44
flow-through free flap in reimplantation surgery 43–7
flow-through radial flap, marking guides 38–9
flow-through radial mid-forearm free flap
anatomy and dynamic concept 42
one-stage coverage, revasculized limbs 41–3
Food and Drug Administration (FDA) 101
forearm clinical outcome after 10
years complete independence, DLA accomplished 222
forearm composite flap including PL and FRC performed 221
forearm cutaneous sphacelous as shot gun injury 282
post-surgical motor function (extension) 282
Index 419
post-surgical motor function (flexion) 282

forearm follow-up after 5 months, donor sites as unsightly with limited active range 222
forearm MP joint release 221
forearm-carpal defects 81
FPL (flexor pollicis longus), secondary reconstruction 197
fracture stabilization 296–7
with external fixation 296
free dermal flow-through venous flap 44, 46–7
free flaps 33–47
disadvantages 54
management principles 33–9
see also distally pedicled radial forearm flap;
ulnar forearm flap
free functioning muscle transfer 251–7
muscles utilised 251–2
free muscle transplantations 256–7
free serratus anterior muscle flap, soft tissue repair, post radical incision, showing cement spacer
289
free vascularized nerve graft, microvascular sutures 137–8
freeze dried allograft, unstable epihyseal fracture, distal radius, repair stages 62
friction avulsion
dorsum of hand with bone and carpometacarpal joint exposure 53
debridement, joint stabilization and grafting 53
early result 53
friction injury to dorsum of hand, loss of extensors 2nd 3rd and 4th and common to 5th 265
FTIR (Fourier Transform Infrared) spectroscopy 101
function restoration 292
fusion of the elbow, indications 129
fusion of wrist, approach 130
G
gastrocnemius muscle 252
gastronemius muscle 255
generalised sepsis, treatment option 300
gentamicin 95, 300
giant cell tumours 111
Gilbert’s procedure, skin incision, non-vascularized graft 93
glenohumeral joint, infection 28
glenoid rim, reconstruction 64
Godina’s principles 23
gracilis muscle 36, 255
distal-middle and proximal pedicles 252–4
as main proximal neurovascular pedicle 251–2
transfer for elbow flexion, surgical technique 252
transplantation on the intercostal nerves 254
gracilis muscle transfer post-elementarectomy, bone shortening 279
gun-shot injury
emergency treatment composition 289–90
secondary treatment 290
Gustilo IIIB open fracture, elbow with large soft tissue defect 68
Index 420
H
hemi-arthroplasty, treatment 121
high riding humeral head, total joint replacement 123
high voltage injury, web of hand 55
Highet scale, muscle power grade M0-M5, British Medical Council 175
HLA (human leucocyte antigen) 313
‘hook deformity,’ fixed 218
human allotransplant of a digital flexion system vascularized on the ulnar pedicle 235–8
human vascularized allotransplant, digital system by microsurgery 236
humeral diaphyseal defect 81
humerus, autogenous reconstruction 65
humerus reconstruction, recipient site considerations 76
Hunter active tendon prosthesis 184
Hunter two-stage technique 197, 217, 293
hydroxyapatite implants 102
I
ideal nerve conduit, theoretical model 153–4
idiopathic scoliosis 100
iliac crest, as common donor site 61–4, 70
immunosuppressive treatments 147
implant arthroplasty, pathological fracture 119–20
index finger
1 year follow up, unable to actively extend finger 208
MP joint stiffness, unrecognised fracture dislocation 207
infection, surgical management 295–300
initial fracture to shoulder arthroplasty, classification system 122
injury assessment and evaluation of tissue, from skin surface to depth of bone 288
intercalated bone graft, peroperative view, clavicle 65
intercalated tendon graft 186
interfascicular autografting 148
interpositional tendon graft 270–1
intraarticular and extraarticular non unions, general categories 67
irrigation and debridement 295–6
ischaemic contracture, left lower arm, fingers fixed, severe flexion contracture 176
isolated flexor digitorum profundus injury 199
ITBS (immuno therapy for specific bacteria) 87–8
iterative debridements and excisions, prior to reconstruction 292
J
‘jig’ system, with newer implant design 121
joint allografts, as salvage procedure 67
joint fusion
indications 125
severe traumatic defects 125–32
techniques 125–6
joint reconstruction, choice of technique 112–13
joint replacement
as secondary procedure 117–23
for traumatic bone loss at the elbow 117–20
joint replacement for traumatic bone loss at the shoulder 120–3
Index 421
joint transfer 110–11

choice of technique 112–13
joint transfers and joint reconstruction 109–15
fundamental aspects 109
joints reconstruction procedures 292
L
large bone defects, donor sites 76–7
large defects reconstruction in children 303–10
antibiotic treatment 308–9
indications 304
nerve regeneration and complete intrinsic muscle recovery 308
peripheral nerve lesions 307–8
septic arthritis of the elbow joint 307
surgical treatment
bone and articular defects 306–7
soft tissue defects 305–6
traumatic arm amputation, child 7 years 308
late sequelae of flexor tendon grafting 199
lateral antebrachial cutaneous nerve 138–40
lateral arm flap with inverted flux see recurrent radial flap
lateral fascial intermuscular septum, forearm 42
lateral forearm flap 282
lateral saphenous nerve, technique to harvest 138
latissimus dorsi island flap 36
after tumour resection, end-toside radial nerve, elbow improvement 173–5
transposed, intraoperative view 26
latissimus dorsi muscle 252
lesions assessment and definition, final goal of treatment definition 287–8
llizarov apparatus application 89, 95
and compactotomy radiographs 92
olive for compressionstabilization of focus while distraction is taking place 90
local upper extremity graft, disadvantages 63
long cortical autogenous grafts, fibula bone 63
long fingers and inability to extend the wrist 206
long nerve defects, end-to-side neurorrhaphy: as alternative reinnervation 169–78
longitudinally oriented suture material 158
loop technique, advantages 197
low humeral fracture
bone loss
range of pain-free motion 118–19
stability restoration with linked modular implant 118–19
bone loss at 1 year 118–19
low median-ulnar nerve palsy 269
lymphatic network 280
M
McGregor’s flap 284
Mackinnon’s clinical series 148
macroporous biphasic calcium phosphate (MBCP) 101
Index 422
macroporous calcium phosphate ceramics 102

malignant ossifying fibromyxoid tumor 25, 27
MCDAS (multimicrovascular collagenic dynamic absorbing system) 227–8
medial antebrachial cutaneous nerve 138
medial gastrocnemius with the sural nerve 255
metallic prosthetic replacement 39
methylmethacrylate, usage 121
microvascular graft with arthrodesis of the wrist, spacer removal 97
middle of a muscle graft (‘sandwich graft’) basal laminae scaffolds 158–9
Millesi technique, nerve grafting 139–40
monoclonal antibodies, antirejection therapy 147–8
MP(metacarpophalyngeal) joints 292–3
associated release, silicone rods under flap, Hunter’s technique 293
multicomponent flaps 243
muscle and musculocutaneous flaps 35–6
muscle transplantation and end-toside suture of thoracodorsal nerve os mucle graft to median nerve
176
muscular sphacelous, of upper limb, significance of surgical evaluation 278
muscular sphacelus (tearing away of the entire upper limb) 278
musculocutaneous free tissue transfers 36
myocutaneous latissimus dorsi flap, successful innervation, by end-to-side neurorrhaphy 176
myoglobinuria 279
myostatic contracture 205
N
Narakas technique 140
Neer prosthesis 122
neighbouring motor selection 186
nerve allografts 146–9, 159–60
history 146–7
nerve defect repair, veins 160
nerve gap distance, and repair type influenced time to earliest reinnervation 158
nerve grafting 137–49
different types 137–8
indications 141–2
postoperative care 141
results 142
technique and methods 139
tendon used as nerve graft 161
procedural stages 161
nerve grafts 154–5
nerve regeneration, ‘neurotube’ 149
nerve sutures as procedure, in emergency 281
nerve tubes 149
neurotrophic factor, example 160
non-pedicled allografts 110–11
non-pedicled epiphyseal autograft 111
non-vascularized allografts, experimental data in favour 147–8
non-vascularized trunk graft 137
Index 423
O
oblique transcarpometacarpal amputation
4 months post-surgery appearance 44–5
bone fixation of amputated part, without shortening 44
free flap harvesting 44
left hand 44–5
olecranon fracture and non-union 67
omolateral lateral arm flap, planning 53
omothbracic disarticulation 278–9
one bone arm creation
bone grafting and osteosynthesis 299
infection resolution, pro-supination was lost 299
one bone forearm, pronosupination sacrificed 298
one-stage reconstruction, with composite tissue transfer 247
open fracture
infected non-union 92
plate osteosynthesis for stable internal fixation, well vascularized soft tissue coverage 244
open fracture of elbow, grade IIIC, with severe bone loss: ipsilateral fracture of radius and ulna 297
open fracture of forearm and wrist, result 96
open grade IIIC fracture
serial debridements 298
radiographs 299
open grade IIIC ulna and radius fracture, severe infection with bone and soft tissue loss 298
opponensplasty 269, 271
osteoarticular allograft 65
osteoarticular loss, at shoulder level 65
osteochondral allograft, flexion-extension of wrist maintenance, with pro-supination 69
osteoconductive materials 99–101
osteocutaneous fibula flap 246
osteomyofasciocutaneous flaps 39
osteosarcoma 111
P
palmaris brevis tendon graft 232
palmaris longus tendon 262
PALS (paediatric advanced life support) 304
pandiaphytes of ulna bone
complete reconstruction of ulna 87
post ITBS and antibiotic therapy 87
Paneva-Holevich technique 198
Papineau technique 298
paprika sign 25
parascapular flap to left hand, function testing 3 months later 245
parascapular flap to the right forearm with transfer of remaining tendons to achieve residual
function;
partial nerve reconstruction 245
parosteal osteogenic sarcoma, proximal humerus, procedure and recovery stages 78
Pasteurella spp. 309
pathognomonic liquefactive necrosis, ‘dishwater pus’ 27
pathological fracture, implant arthroplasty 119–20
pectoralis major muscle 252
Index 424
pectoralis minor muscle 252

pedicellate fasciocutaneous radial forearm flap 68
pedicle dissection and section 94
pedicled epiphysis 111–12
pedicled fasciocutaneous and adipofascial flaps 7–19
pedicled latissimus dorsal island flap transposition
18 months post, deep right shoulder infection 27
shoulder defect 30
outcome postoperatively 30
pedicled latissimus dorsi flap 24–6
right upper extremity, repeated debridement, necrotizing fasciitis 27
pedicled latissmus dorsal island flap, transposition, shoulder defect 29
pedicled muscle and musculocutaneous flaps 23–9
pedicled myocutaneous latissimus dorsi flap 28
pedicled pectoralis major flap 25
design 28
pedicled staged tendon grafting technique 197–8
pedicled tendon graft 184
pediculated latissismus dorsi flap, plastic reconstruction 278
periprosthetic fracture massive bone loss 119
stabilization linked snap fit revision prosthesis 119
PL (palman’s longus) tendon, raised flap 38–9
plaster-of-Paris see calcium sulphate
plastic reconstruction, by regions, principles 281–4
plate fixation, by autogenous bone grafting 64–5
pollicization operation, trapeziometacarpal joint 269–70
poly-3-hydroxbutyrate (PHB) 149, 161
polyglycolic acid (PGA) tubes 156
polyhydroxybutyrate 161
polylactate caprolactone (PLC) 158
polymethylmethacrylate beads impregnated with gentamicin sulphate 298
post-traumatic infected substance loss 87–104
posterior bone graft, harvesting 63
posterior interosseous flap 305
complications 16
pedicled distally, inverse vascularization 8–9
planning and completion example 9
posterior interosseous forearm flap 13
surgical technique 13–14
Potenza’s principle 228
preservation and reconstruction of the pulley system 192
primary total elbow replacement, indications 117–18
prior bone reconstruction failures 77
Pro-Osteon 500R, interporous hydroxyapatite 103–4
prosthetic arthroplasty 122
large loss linked 110
proximal fixation, Pulver weave technique 191–2
proximal humerus allograft 78–9
‘proximal interphalangeal joint motored finger,’ circumstances for use 198
proximal interphalangeal joint (PIP) 184–5
proximal metaepiphysis of the tibia, cancellous bone removal 128
Index 425
proximal migration of radius with ulnar plus 91

proximal sphacelus/amputation 279
proximal suture, synthetic braided suture 192
pseudoarthrosis 88–95
atrophic form 88
hypertrophic form 88
infected, stability as goal 89
infected radius: outcome of open fracture 91
infected right humerus 89
proximal compactotomy assembly required model 92
recovery stages 89–90
treatment philosophy 89
ulnar plus, post 4 months treatment 90
various forms, treatment considerations 89–95
Pseudomonas spp. 300
pulley reconstruction
based on remnants 194
methods 194–5
single or multiple loop technique 194
Pulvertaft’s method, weave technique 231
pyrocarbon prosthesis, as joint replacement 208
R
radial artery blood supply contribution, to thumb and index finger 18
radial artery forearm flap 262–3
radial flap transposition, post proximal/distal arterial, venous anastomoses 38–9
radial forearm flap 7, 37
complications 16
with large calibre vessel 244
radial recurrent flap, complications 16
radial and ulnar arteries thrombosis, with infection 282
radial/ulnar forearm flaps, with distal pedicle, inverse vascularization 8
radical debridement
infection control 41
principle 52
radical debridements, free latissimus dorsi transfer, external fixation reapplication 299
radio-carpal fusion with Darrach procedure 132
radio-carpal fusion with plate and screws preserving prono-supination 132
radio-ulnar bridging callus 67–8
radio-ulno-carpal fusion in semipronation with sliding of a radial stick and 3 Kirschner wires 132
radius-recurrent adamantinoma post curettage 81–2
radius/ulna diaphyseal defect 81
rat sciatic nerve, long sutures, bridging gap, generation of new nerve structure 158–9
reconstruction areas and flaps used 15
reconstructive procedure, selection, in tendon defect repair 186
reconstructive surgery
general strategy and components 288
greater salvage and speedier restoration, structure and function 23
rectus abdominis 36
recurrent radial flap 14
Index 426

recurrent ulnar flap
reconstruction area, and procedure result 10–11
replantation of arm
biceps destroyed
gracilis transplantation with neurovascular anastomoses 253
active elbow flexion after 8
months 253
revascularization syndrome 279
reverse flow pedicle flap 282
rifampicin 300
rigid internal fixation and bone grafting, as non-union procedure 65–6
road-traffic accident
MP joint release, and follow-up 221
preoperative radiographs 221
Rose’s technique, nerve grafting 145
rotator cuff repair, post-surgical shoulder infection 28
RTA (road-traffic accident) 220
metacarpal fractures exposed 220
S
salvage free flaps 54
saphenous vascular graft 279
scapular free tissue transfer 37
scapular girdle 64–5
scapulohumeral defects, surgical technique 77–80
scapulohumeral reconstructions 81
Scheker’s protocol 264
Schwann cells
basal laminae 154–5
Matrigel suspension, introduction to tubes, successful nerve regeneration factor 158
‘nerve growth factor, ‘ with resorbable filaments 149
second toe of foot, free tisssue transfer 37
secondary flexor tendon salvage, natural method 228
serratus anterior 36
severe bilateral Dupuytren contracture 17
severe contusion injuries or necrotizing injuries, consequent follow-up requirement 242
severe crush defect of the extensor muscle group 244
severe crush injury
intraoperative situation after nerve, and tendon repair and vascular interposition, vein graft to
radial artery 247
segmental bone loss, median nerve laceration, radial artery loss, severe semicircular soft tissue loss
247
severe defect, definitions 3
severe fractures forearm 67–9
severe high-voltage injury with loss of soft tissue envelope of forearms, muscle substance and
tendons, bilateral involvement of median and ulnar nerves 245
severe infection of the dorsum, of hand and wrist affecting soft tissue 296
severe tendon damage, pseudo-sheath reconstruction 183
shap injury sequelae of palm 1 year follow-up 220
Index 427
intraoperative finding: flexor tendon minigraft to flexor profundus corresponding superficialis

harvested 219
unable to flex index finger, dominant hand 219
shoulder arthroplasty 120–3
shoulder fusion
20 degree of abduction 129
results evaluation 129
shoulder infection, post rotator cuff repair 28
shoulder level, osteoarticular loss 65
Siamese (sister) flaps 42
side-swipe or gunshot wound, common complications 120
silicone artificial regeneration chambers 149
simultaneous arterial reconstruction, several flaps used in conjunction as flow-through flaps 244
single or multiple loop technique, tendon defect repair 194–5
single stage tendon grafting technique 195
skeleton stability, significance 23
skin envelope, radius and extensor tendons of wrist and fingers, vascularization by ulnar artery 289
skin grafts 35
skin and tendon necrosis, by chemotherapeutic agent 292
sliding unit, tendon and surrounding sheaths 228
soft tissue defect of the dorsum of the hand after abrasion injury 243
soft tissue envelope repair 290–1
soft tissue reconstruction
with a large muscular latissimus dorsi flap plus skin graft after tendon repair and osteosynthesis
244
late, higher infection and flap complication rate 23
surgical anatomy 24–5
soft tissue reconstruction with a scapular skin flap and a parascapular fascia extension, extensor
tendon, new gliding tissue 243
soft tissue volume increase, with simultaneous harvesting of soleus muscle 246
SOS Hand (round-the-clock) 277
sphacelous of the distal forearm and wrist 282
sphacelous of the wrist and dorsal aspect of hand
with avulsion of proximal insertion of extensor tendon 283
radiographical image 283
reconstruction of all structures 283
sphacelous/amputation
complete
flexion 1 year after surgery 279
right forearm and complete right forearm 279
spinal surgery, ceramics 100–1
SRS (Norian skeletal repair system) 102
stability in joints, ‘sloppy hinge,‘ and semi-constrained implant 118
staged tendon grafting techniques
rehabilitation following stage one 196
stage two, complications 198
Staphylococcus aureus 300, 309
Staphylococcus epidermis 300
strong elbow flexion, lifting 2kg 254
subankylosis of DIP joint, in association to disruption of the flexor apparatus of long finger 216
subcutaneous rupture of flexor profundus
middle finger, right hand 215
Index 428
palmaris longus, as graft source 215

preoperative clinical picture 215
single stage tendon grafting procedure to the profundus through intact sublimis, positive
outcome 215
subscapular system: indication for flap from, including a segment of medial or lateral scapular rim
246
superficial ulnar artery 16
‘superficialis finger’ 195
‘superficialis finger’
‘follow-up at 1 year, active flexion at DIP joint, with stiffness overcome by active motion’ 217
‘re-established’ 217
sural nerve 138
sural nerve grafts 137
surgical techniques, as last step in surgeon’s methodology 290–2
suturing technique, extensor tendon grafts 204
swan-neck deformity 202
T
tactics, defined 288–9
TADA 205–6
TAM (total active motion) 199
tardy ulnar nerve palsy 66
temporal fascia free tissue transfer 37
temporary external fixation application, emergency treatment post debridement: brancial artery
reconstruction 297
tendofasciocutaneous dorsalis pedis flap
13 months post-surgery 40
dorsum left foot 40
raised flap, anatomy 40
tendon, optimal functional value when it is surrounded by its original sliding 228
tendon allografts 183
tendon defect repair
anatomical conclusions 228
neighbouring motor selection 186
technique 230
transplantation technique 236–7
tendon grafting 203–5
distal fixation 190
end-to-side suture 187
fixed deformity 199–200
flexor tendon grafting, standard technique 189–90
graft selection 187–8
biological considerations 187–8
graft sources
extensior proprius tendons 189
extensor digitorum longus of the toes 189
flexor digitorum superficialis 189
palmaris longus 188–9
plantaris longus 189
longer fingers, FCU (fleuro carpi wraris) 205
proximal fixation 191–2
Index 429
tendon allograft (xenograft) 187

tendon prosthesis 187
tendon sheath isolation 190
tendon transfer 187
using extensor tendons of the toes, and clinical result 293
tendon physiology, new physiology 228
tendon reconstruction, postsurgical repair 243
tendon sheath couple concept 228
tendon spacers, perioperative view 282
tendon vascularization with peripheral collagen 228
tensor fascia lata 36
tensor fascia lata flap (TFL) 241
tetanus prophylaxis, for children 309
thenar eminence, severe trauma, management considerations 269
thenar injury, type 4, combined burn-crush 271
thermal injuries in children 303
thermal injury with crush component at dorsum of hand, debridement and skin resurfacing with
groin flap 222
thermoplastic splint for dynamic motion protocois after tendon transfer 245
thoracoacromial pedicle and pectoral nerve, cranially reflected pectoralis major muscle 28–9
Tikhoff-Linberg resection 25–6
timing of reconstruction
open wounds, upper extremity, Breidenbach (1989) definition 52
terms 51
Tinel sign, nerve grafting 144
tissue engineering and biotechnology, hand and upper limb surgery advances 313–18
tissue engineering and biotechnology application 313–18
tissue engineering components 314–15
biomaterials 315
bone 315–16
cartilage 316
cells 314
cellular signals 315
nerves 318
scaffold or matrix 314
tendons 316–17
vessels 317–18
tissue engineering nerve conduit, for bridging nerve defects 154
tissue replacement and regeneration 313–14
tobramycin 300
total elbow arthroplasty 67
total limb reimplantations, conclusions associated 280–1
total recovery of motion and return to work 231–2
TPF (temporal artery flap) 243
transmetacarpal amputation
5 months post-surgery 46–7
dorsal aspect of stump 46–7
immediate post-operative result 46–7
palmar aspect of stump 46–7
right hand 47
transplantation technique (from a cadaver) 236, 237
TRAP (tartrate resistant acid phosphatase) 101
Index 430
trapezio-metacarpal joint, and pollicization operation 269–70

traumatic sphacelous/amputation at elbow and proximal forearm levels
11 years 2 months later 283
active finger flexion 283
train accident 283
trephine forceps 63
tricalcium phosphate 100
trochlea reconstruction 67–9
trunk grafts 137
tube contents
manipulation/modification, regeneration improvement 156
tubes:
experimental background 155–6
tubular repair 155
U
ulnar forearm flap 7, 9
complications 16
surgical technique 9, 13
ulnar nerve graft, wrist level, procedural stages 141
ulnar pedicle 236
ulnar pulp
sensory reinnervation
replanted thumb
electric stimulation ulnar side of thumb 173
end-to-side neurorrhaphy avulsed finger nerve to median nerve 173
full functional recovery 4
years 173
Nihydrin test showing good recovery 173
ulnar recurrent, complications 16
ulnar trail system see ulnar vascular system
ulnar vascularization, specific characteristics 235–6
ulnar vascularized nerve graft to repair median nerve, wrist level, procedural stages and result 144
ulnodorsal septocutaneous flap 17
complications 16
reconstruction for dorsal hand lesion 10
surgical technique 14
upper extremity reconstruction, primary goal 23
upper fibular epiphysis, as vascularized transplant, upper humerus replacement, with distal radius
tumour resection 112
V
vancomycin 300
vascular basis of the flap, confirming safety of the transfer 234–5
vascular pedicles
problematic factors 44
vascularized tendon transfers, results 233–4
vascularization, continuous/and permanent 228
vascularized bone transfer 39
indication, upper limb bone defect 76–7
reconstruction
Index 431
massive bone defects 75–81

historical background 75–6
specific indications, bone defect 76–7
vascularized fibula
non-union distal humerus 94
transfer, postoperative radiograph 80
vascularized fibula transfer, technique 92
vascularized grafting, clinical experience 145–6
vascularized nerve grafts
extensive loss of substance of branchial plexus 143–4
techniques with historical review 142–3
types 143
vascularized tendon transfer discussion 233
transplantation technique (from a cadaver) 236–7
transplantation techniques, functional results 237–8
vascularized tendon transfers anatomical reminder 229–30
basic principles 229
as method of choice
anatomical conclusions 228
physiological conclusions 227–8
technical questions 229
vasculization improvement, benefits 33–4
vasculized bone graft, large bone defects, reconstruction issue 77
vein-muscle conduits 160
vena comitantes (VC), posterior tibial artery, flap inset 268
venous anastomoses 80
venous drainage of the island pedicle flap, satellite veins 13
vessels (arterial, venous, lymphatic) networks 279–81
Volkmann’s contracture 252, 279, 287–8
transplantation in the forearm, surgical technique 255–6

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Severe Traumatic Defects of the Upper Limb

Severe Traumatic Defects of the

LONDON AND NEW YORK

ISBN 0-203-63311-3 Master e-book ISBN

ISBN 0-203-63356-3 (Adobe e-reader Format)

Distributed in the USA by

Composition by EXPO Holdings, Malaysia

SOFT TISSUE REPAIR: FLAP TECHNIQUES

2 Pedicled fasciocutaneous and adipofascial flaps

3 Pedicled muscle and musculocutaneous flaps

5 Emergency free flaps for the reconstruction of open injuries of the

6 Bone auto-and allografts in post-traumatic reconstruction of the upper

10 Joint transfers and joint reconstruction

12 Joint fusion in severe traumatic defects of the upper limb

NERVE DEFECT REPAIR

14 Bridging nerve defects: the role of tissue interpositioning

15 End-to-side neurorrhaphy: an alternative method for reinnervation in

16 Conventional tendon grafting

18 Composite tissue transfer in the upper extremity

19 Free functioning muscle transfer

20 Combined soft tissue and tendon reconstruction: the dorsum and

21 Principles of emergency reconstruction

24 Reconstruction of large defects of the upper limb in children

Francisco del Piñal

Norman Della Rosa

Radial forearm flap

Ulnar forearm flap

The posterior interosseous forearm flap

Ulnodorsal septocutaneous flap (distal ulnar artery island flap)

Recurrent radial flap (lateral arm flap with inverted flux)

Recurrent ulnar flap (medial arm flap with inverted flow)

Table 1 Reconstructed areas and flaps used.

Table 2 Complications of the different flaps used.

Amarante J (1990) Retalhos Septocutâneos de Fluxo Invertido Contribuição Para o seu

Amarante J, Costa H, Reis J, Soares R, Carvalho F (1987) Um novo conceito em cirurgia

Costa H, Comba S, Martins A, Rodrigues J, Reis J, Amarante J (1991) Further experience

Maillard G, Meredith P (1991) Bilateral pinch reconstruction. Versatility of the

Schoofs M, Bovet J, Panconi B, Amarante J, Daoud G, Baudet J (1983) Le Lambeau

Pedicled latissimus dorsi flap

Pedicled pectoralis major flap

Illustrative case reports

Bunnell S (1970) Surgery of the Hand. JB Lippincott: Philadelphia.

Muscle and musculocutaneous flaps (Table 1)

Fascial and fasciocutaneous flaps (Table 2)

Table 1 Musculocutaneous free tissue transfers.

Motor nerve Thoracodorsal Long thoracic Segmental Superior Anterior

Table 2 Fasciocutaneous free tissue transfers.

of arm lateral peroneal,

saphenous graft to the ulnar artery. (e) Appearance at 4

Emergency free flaps

One-stage coverage and revascularization of traumatized limbs by a flow-

The flow-through free flap in reimplantation surgery

• tension at the site of anastomosis

Allien Y, Gomis R, Yoshimura M, Dimeglio A, Bonnel F (1981) Congenital

Honda T, Nomura S, Yamanchi S, Shimamura K, Yoshimura M (1984) The possible

Currently, debridement of all necrotic and contaminated tissues followed by immediate

Table 1 Definition of timing of reconstruction of open wounds of the upper

substitute), but need to be adequately covered as soon as possible to retain useful

The receiver site

Bone auto- and allografts

Demineralized bone matrix (Urist et al 1967) shows osteoinductive activity

Choice of bone graft

How to obtain a bone graft?