Review of the optimal timing and technique for extensor tendon reconstruction in composite dorsal hand wounds

Abstract

Aim: The management of complex dorsal hand wounds with extensor tendon loss is controversial. Treatment has focused on soft tissue coverage, but there is limited evidence comparing immediate vs. staged tendon reconstruction. This review evaluates existing literature to determine the optimal management of composite hand defects. Methods: A MEDLINE database review was performed including objective measurements such as number of operations, total active motion, grip strength, days to maximum range of motion (ROM), and return to work. Data extraction included demographics, surgical techniques, complications, and relative outcome. We compared primary and secondary staged reconstruction to correlate any significant differences in outcome and determine optimal timing and technique for extensor tendon reconstruction. We extracted information on flap types including regional and free tissue transfer with tendinous components vs. staged tendon grafts. Results: Comparison of outcomes showed that patients with immediate reconstruction had fewer operations, faster return to maximum ROM, and greater chance of returning to work. The most successful single stage flaps include the radial forearm, suitable for reconstructing one to three tendons and the dorsalis pedis for three or four tendons; however, there were significantly more complications in immediate reconstruction particularly regarding donor site morbidity. Pedicled flaps had better total active motion. The two-stage approach resulted in acceptable functional outcomes without significant complications.

Early total reconstruction for a Gustilo type IIIB open forearm fracture associated with avulsion injury of multiple extensor tendons: A case report

“…Regarding the optimal timing of reconstructive surgery, immediate reconstruction reportedly allows for a faster recovery to the range of motion, fewer operations, and a greater chance of returning to work [ 7 ]. The obvious advantages of a single-stage technique include the ability to initiate rehabilitation earlier.…”

Bilaminate Synthetic Dermal Matrix versus Free Fascial Flaps: A Cost-Effectiveness Analysis for Full-Thickness Hand Reconstruction

“…No head-to-head studies comparing secondary procedures for these two techniques exist to our knowledge, though conventional teaching would suggest that soft-tissue elevation and subsequent tendon gliding may be more facile for a flap-based reconstruction rather than graft/dermal matrix that has taken to the wound bed. 28 Finally, while we uncovered literature that supported superior range of motion outcomes for free fascial flap reconstruction, it is questionable whether the final total active motion difference between bilaminate dermal matrix and free fascial flap reconstruction is clinically significant for patient outcomes. However, given prior work in the care of burned hands, which has defined 220 degrees of TAM as functional, 29,30 each degree of motion around this threshold may be clinically valuable.…”