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Reconstructive Surgery

Hand reconstruction: congenital anomalies (syndactyly, thumb hypoplasia), nerve repair (VNGs), and microsurgical transfers for complex defects.

168 citationsUpdated Oct 2026

Overview¶

Reconstructive decision making in the elbow, wrist, and hand is currently driven by surgeon experience and consensus rather than high-quality evidence [1]. Because trauma is the usual precursor, standardization is seldom possible, requiring surgeons to be keenly aware of all possible approaches to ensure safe and satisfactory results [6]. The "reconstructive elevator" concept guides this process, allowing surgeons to select more complex reconstructions for specialized function and aesthetic outcomes rather than adhering strictly to the simplest technique [15]. For severe hand injuries, combined reconstruction strategies based on defect characteristics offer acceptable complication rates and good functional recovery [4].

Indications vary by injury mechanism. Firework-related hand injuries often require reconstruction rather than repair, with many patients needing secondary procedures; prevention remains the best treatment [2]. In tetraplegia, no criterion standard measures exist to evaluate the consequences of reconstructive arm and hand surgery, though surgical indication and rehabilitation are critical factors for functional outcomes [22, 44]. For traumatic thumb loss, any reconstruction procedure is beneficial compared with no reconstruction [56]. While different microsurgical transfer techniques suggest freedom of choice, these options are considerably restricted if all functional and cosmetic requirements must be met [20].

Headline outcomes indicate that the success of reconstructive surgery relies on functional improvement in addition to technical achievement [31]. The risk of adverse events is acceptable across all flap types for digital soft tissue defects, with an overall adverse event rate of 5.4% and reoperations needed in approximately 2% of cases for local flap reconstruction [23]. Free flap reconstructions provide critical advantages over non-microsurgical techniques for digital soft-tissue defects, offering early mobilization and appropriate coverage with acceptable donor morbidity [17]. Staged opposition transfer is warranted for its increased safety and consistently good functional outcome [19]. Continued enhancement in immune modulation, surgical indication, patient selection, and posttransplant care is expected to make vascularized composite allograft a major milestone in reconstructive surgery [146].

Anatomy & Pathophysiology¶

Bony Anatomy¶

The skeleton of the hand and wrist comprises 27 bones, 19 of which are long bones [36]. This structure is organized into five rays, each forming a polyarticulated chain of metacarpals and phalanges [36]. The base of each metacarpal articulates with the distal row of the carpus [36]. The radioulnocarpal articulation possesses two axes of movement, supplemented by a third axis of pronation and supination from the forearm [36]. Consequently, the wrist exhibits three axes of movement, permitting the hand to assume any spatial configuration necessary for grasping [36].

The radial ray, or first ray, is the shortest, consisting of only three bones: a metacarpal and two phalanges [36]. The trapezium is angled anteriorly out of the carpal plane, creating an angle of approximately 45 degrees between the first and second metacarpals in the sagittal plane [36]. In terms of length, the thumb metacarpal is the shortest, while the index metacarpal is by far the longest [36]. The proximal and middle phalanges of the long and ring fingers are longer than those of the index finger [36]. Epiphyseal plates are located at the proximal ends of the phalanges and the first metacarpal, whereas they reside at the distal ends of the other metacarpals [36].

The hand presents a longitudinal and transverse concavity, forming a cup shape with palmar concavity when the thumb is positioned next to the index finger [36]. The transverse axis of the palm is oblique, positioned more distally at the index metacarpophalangeal joint and more proximally at the fifth metacarpophalangeal joint [36]. This transverse axis forms an acute angle of approximately 75 degrees with the longitudinal axis [36].

Musculature & Extensor Mechanism¶

Control of digital posture requires a complex balance of extrinsic and intrinsic muscle forces [33]. Extrinsic muscles originate outside the hand and insert on the hand or carpus, while intrinsic muscles have both origin and insertion within the hand [33]. The extrinsic extensors traverse six distinct fibroosseous retinacular compartments at the wrist level [33].

Compartmental Anatomy: * First compartment: Contains the abductor pollicis longus and extensor pollicis brevis [33]. * Second compartment: Contains the extensor carpi radialis longus and extensor carpi radialis brevis [33]. * Third compartment: Contains the extensor pollicis longus, which runs longitudinally down the forearm and turns abruptly radialward about Lister tubercle [33]. * Fourth compartment: Contains the extensor indicis proprius, lying deep to the four tendons of the extensor digitorum communis [33]. * Fifth compartment: Contains the extensor digiti quinti [33]. * Sixth compartment: Contains the extensor carpi ulnaris tendon, which inserts at the base of the little finger metacarpal [33].

The principal bony insertion of the extrinsic digital extensors is on the dorsal proximal aspect of the middle phalanx [33]. Metacarpophalangeal joint extension is provided by extrinsic extensor force transmitted through the sagittal bands [33]. Distal interphalangeal joint extension is achieved through conjoined lateral bands composed of tendinous slips from both extrinsic and intrinsic tendons [33]. Digital extensor tendons are stabilized over the midline of the metacarpophalangeal joint by their attachment to sagittal band fibers [33]. Rupture or attenuation of these sagittal band fibers allows the extrinsic extensor tendon to sublux to the ulnar side of the metacarpal head, causing ulnar deviation of the finger [33].

There are seven interosseous muscles: four dorsal and three volar [72]. The dorsal interossei act as abductors, while the volar interossei act as adductors [72]. The middle finger possesses two dorsal interossei (abductors) and no volar interossei (adductors) because the central axis of the hand lies within it [72]. The deep head of each dorsal interosseous muscle forms a lateral tendon, or lateral band, at the level of the MP joint [72]. This deep head flexes and weakly abducts the proximal phalanx while extending the middle and distal phalanges [72]. The volar interossei form the ulnar lateral band of the index finger and the radial lateral band of the ring and little fingers [72]. The abductor digiti quinti and flexor digiti quinti brevis are similar in both structure and function to the superficial and deep heads of the dorsal interossei, respectively [72].

Flexor Mechanism & Tendon Sheaths¶

The extrinsic finger flexors are the flexor digitorum profundus and the flexor digitorum superficialis [33]. The flexor digitorum profundus inserts on the proximal volar aspect of the distal phalanx [33]. It flexes the distal interphalangeal joint as well as the proximal interphalangeal and metacarpophalangeal joints [33]. The flexor digitorum superficialis acts as a flexor of the proximal interphalangeal and metacarpophalangeal joints [33].

The fibroosseous tunnel, or digital flexor sheath, consists of annular pulleys that provide mechanical stability and cruciate pulleys that provide flexibility [91]. The A2 and A4 pulleys are the most essential in maintaining the mechanical advantage of the flexor tendons [91]. The tenosynovium lining the fibroosseous tunnel supplies both nutrition and lubrication to the poorly vascularized flexor tendons [91]. Within the sheath, tendon vascularity is supplied via the vincula system, specifically the vinculum longus and brevis [91].

The lumbricals originate from the radial side of the index, middle, ring, and little fingers in the palm [91]. Innervation of the flexor digitorum profundus for the index and middle fingers is via the anterior interosseous branch of the median nerve [91]. The profundus of the ring and little fingers is innervated by the ulnar nerve [91]. The entire flexor digitorum superficialis muscle receives innervation from the median nerve [91]. The flexor pollicis longus inserts into the proximal base of the thumb distal phalanx and is innervated by the anterior interosseous branch of the median nerve [91].

Vascular & Cutaneous Anatomy¶

The arteries of the thumb vary in both size and number, making surgical reconstruction delicate [84]. The "princeps pollicis" artery, a terminal branch of the radial artery, crosses the first intermetacarpal space and runs along the ulnar side of the first metacarpal bone [84]. In anatomical studies, only 15% of dissections fall into the category of the classical layout of palmar arteries of the thumb [84].

The dorsal skin is thin and lined by a horny layer that is only 0.02 mm thick [93]. Unlike the palm, the dorsal skin possesses a normal pilosebaceous system [93]. Flexion of the fingers produces significant lengthening of the dorsal skin [93]. In the middle finger, the distance between the wrist and the ungual fold shows an average increase of 3 cm as the finger moves from extension to full flexion [93]. Flexion at the metacarpophalangeal joint alone requires an average skin lengthening of 1.25 cm [93].

Skin Coverage Dimensions: * Thumb distal to MCP: Approximately 9 cm wide and 8 cm long [77]. * Thumb and first metacarpal loss: 13 cm wide and 12 cm long [77]. * Palmar and dorsal hand surfaces: 12 cm by 10 cm [77]. * Each finger (palmar and dorsal): 7 cm by 10 cm [77]. * Skin grafting/flaps for both sides of hand and digits: Requires 20 cm by 20 cm [77].

Functional Biomechanics & Pathophysiology¶

Painless and full hand function requires seamless integration of joints, muscles, and nerves to complete even the most basic task [11]. The adaptability of a mobile finger unit results from the course traversed by the sensate tip of the finger, which follows an equiangular spiral [12]. The injured hand demonstrates a cascade of functional disasters where wrist extensor loss allows the hand to fall into wrist flexion, resulting in finger flexion, edema, and proximal interphalangeal joint flexion [12]. The grip of the hand can never exceed the strength of the wrist extensors to neutralize the flexor tendon’s ability to flex the wrist [12]. The transverse carpal ligament prevents bow-stringing of flexor tendons [12].

The metacarpal arch possesses significant adaptability due to the mobility of the peripheral metacarpals [80]. The index metacarpal is the most firmly fixed [80]. The ring metacarpal has about 10 degrees of mobility in flexion and extension [80]. The fifth metacarpal has a range of flexion–extension of approximately 20 degrees [80]. The keystones of the longitudinal arches are the metacarpophalangeal articulations, whose thick anterior glenoid capsules, the volar plates, prevent hyperextension [80]. An imbalance between the three muscular systems, especially an "intrinsic-minus" situation (loss of the intrinsic muscles), results in a break in the continuity of the curves at the level of the metacarpophalangeal joint [80].

The position of each articulation depends on the equilibrium of forces acting at that level, which is subject to the position of the immediately proximal articulation [92]. The wrist influences the position of the metacarpophalangeal joint; the metacarpophalangeal joint affects the position of the proximal interphalangeal joint, which in turn affects the distal interphalangeal joint [92]. Almost all movements in the hand occur around oblique and variable axes, resulting in combined movements that permit optimal orientation of the phalanges at the time of prehension [92]. The proximal interphalangeal joint is the most vulnerable joint in the burned hand because the extensor tendons are poorly protected [38].

Hand function after bone loss depends on maintaining length and alignment of the metacarpals and preserving joint motion [142]. The ulnar 2 digits play a significant role in overall grip strength of the entire hand [185]. The fibula is considered more suitable than the rib for bridging forearm gaps due to its favorable biomechanic properties [194].

Classification¶

General Principles: Reconstructive surgery is seldom standardized because trauma is usually a precursor, requiring surgeons to be aware of all possible approaches to ensure safe and satisfactory results [6]. The concept of the 'reconstructive elevator' allows surgeons to choose more complex reconstructions to account for specialized function and aesthetic outcomes rather than adhering strictly to the simplest technique [15]. A thorough understanding of complex anatomy and a working knowledge of reconstructive options are essential for successful outcomes in failed extensor tendon repairs [18].

Thumb Hypoplasia: Blauth’s classification continues to be helpful for describing the degree of hypoplasia leading to different options of surgical reconstruction [74]. In 1937, Müller introduced the concept of a teratological sequence of increasing severity for thumb hypoplasia, from mild through severe deficiency to absence [251]. Blauth distinguished five grades of thumb hypoplasia based on Müller's concept, distinguishing Grade 2 from Grade 3 according to the presence or absence of a carpometacarpal (CMC) joint [251]. Manske and McCarroll’s 1992 modification of Blauth’s classification moved the distinction based on CMC joint presence into a subdivision of Grade 3, where Grade 3A has a CMC joint and Grade 3B does not [251]. In the Manske and McCarroll modification, the difference between Grades 2 and 3 is redefined by the presence or absence of extrinsic musculotendinous anomalies [251]. Buck-Gramcko suggested adding a Grade 3C to Manske’s modified classification in 1993, in which only the distal third of the metacarpal remained [251]. Smith emphasized the importance of assessing the stability of the metacarpophalangeal (MP) joint in 2002 and suggested subdividing Grade 2 into Grade 2A (ulnar collateral ligament instability) and 2B (global instability of the MP joint) [251]. Complete identification of pathologic structures and anatomic reconstruction is the cornerstone of successful surgical treatment for type IIIA hypoplastic thumb [13]. The aim of surgical treatment for the triphalangeal thumb is to reconstruct or correct the anatomic difference while providing a more acceptable appearance [7].

Ring Avulsion Injuries: Urbaniak et al suggested a practical classification for ring avulsion injuries to guide treatment and assess functional outcome, defining class I as circumferential soft tissue injury with intact or minimally damaged circulation and innervation [255]. In the Urbaniak classification for ring avulsion injuries, class II is defined as incomplete digital degloving accompanied by circulatory interruption requiring revascularization, nerve repair, and soft tissue cover [255]. In the Urbaniak classification for ring avulsion injuries, class III is defined as digital amputation or complete soft tissue degloving leaving nothing but bare bone, joint, and tendon [255]. Kay et al modified class II of the ring avulsion injury classification by determining whether there was arterial [a] or venous [v] insufficiency [255]. Kay et al added an extra category to the ring avulsion injury classification when bone or joint injury occurred, noting that the prognosis was significantly worsened [255]. In the Kay modification of the ring avulsion injury classification, digital amputation and total degloving injury was changed to class IV [255]. The classification of ring avulsion injuries needs modification to clarify the differences between total avulsion of the soft tissue alone and avulsion with amputation [121].

Polydactyly: A proposed radial polydactyly classification system supplements Wassel's classification by providing clear guidance on surgical methods and required surgeon expertise levels [82]. A modified classification for radial polydactyly has been proposed as a practical and utilitarian scheme for nomenclature that may assist comparison of treatment outcomes and individual cases [141].

Soft Tissue Defects: A classification system for hand soft-tissue defects based on size, location, and tissue characteristics has been proposed to guide flap selection [29]. The SATT classification system for open hand injuries is based on identifying the severity of the initial injury and determining whether the involved parts are viable [238]. The SATT classification system for open hand injuries takes into account anatomical localisation (isolated vs. extended), topography (volar vs. dorsal), and type of injury (sharp vs. crush-avulsed) to direct management [238]. A classification of distal digital amputation corresponding to Lister’s classification was used to divide clinical series into groups based on the proximal flap selected for Gigogne flap reconstruction [242]. The graft on flap method is an established solution for treatment of fresh fingertip amputation, especially type III or IV in Allen’s classification, where microsurgical replantation is technically difficult and reattachment of a large amputated portion as a composite graft usually fails [248].

Other Considerations: A retrospective analysis has shown that a classification system is helpful in selecting a surgical option for the treatment of thumb-in-palm deformity in cerebral palsy and spastic paralysis [106]. A classification system and four different treatment strategies based on presenting radiographs have been presented to guide the decision-making process for two-stage hand reconstruction in Apert acrosyndactyly [132]. There is a need for more detailed classification systems and agreed outcome measures to facilitate comparison of outcomes in the management of complete brachial plexus birth injury in the absence of high-level evidence [147]. The American Joint Committee on Cancer/International Union Against Cancer classification is most commonly employed for staging soft tissue sarcomas of the extremities, including assessment of tumor size, nodal status, presence of metastases (TNM-status), and pathological grading [231]. In the 2010 modification of the AJCC/UICC classification for soft tissue sarcomas, patients with regional lymph node involvement are now considered stage III instead of stage IV [231]. The modified evidence-based classification system for failure of limb salvage after reconstructive surgery for bone tumours corrects weaknesses of earlier systems by providing specificity for endoprosthetic, biological, and paediatric failures [69]. A classification system for distal upper extremity bypass vein grafts has been proposed in the context of microsurgical revascularization of the ischemic hand [157]. Complications in pollicization of the index finger were graded using the Clavien-Dindo classification of surgical complications adapted for orthopedic surgery by Sink et al., which includes 5 severity grades based on the treatment required to manage the complication and any long-term morbidity [210].

Outcome Assessment: The Chen criteria for evaluation of function are designed specifically for complete limb replantation after traumatic amputation and are ideal for assessing outcomes of severe complex multisystem injuries due to the variability of lesions [45]. A grade V result category was added to the Chen criteria to indicate amputation, early or late [45]. In a series of 29 limbs undergoing revascularization or replantation, 27 survived for a viability rate of 93% [45]. Among 29 patients with severe complex upper extremity injuries, 11 achieved a grade I functional result, 11 a grade II result, 5 a grade III result, 0 a grade IV result, and 2 grade V results [45]. Postoperative results for Dupuytren’s contracture tend to be better in earlier stages of contracture, with an average of 97% of Stage I patients experiencing results that were at least satisfactory [270]. In studies of Dupuytren’s contracture, 82% of Stage II patients experienced results that were at least satisfactory [270]. In studies of Dupuytren’s contracture, 73% of Stage III patients experienced results that were at least satisfactory [270]. In studies of Dupuytren’s contracture, 59% of Stage IV patients experienced results that were at least satisfactory [270].

Surgical Indications: Toe-to-thumb reconstruction allows the operation to be tailored to a specific injury pattern and patient type [30]. In the treatment of epithelioid sarcoma of the thumb, wide surgical resection is the main element, and flap reconstruction surgery can be proposed in distal locations [37]. Surgical intervention for the burned hand should follow the standard reconstructive ladder and can involve several techniques from simple to complex [159]. The free thoracodorsal artery perforator flap has five types of advanced applications that make it versatile for reconstructing different kinds of soft tissue defects of the extremities [148]. The risk of adverse events in local flap reconstruction for digital soft tissue defects is acceptable across all flap types, with an overall rate of 5.4% and reoperations needed in approximately 2% of cases [23].

Clinical Presentation¶

History and Patient Factors¶

Patients frequently struggle to accurately describe symptoms and may incorrectly attribute pathology to a perceived deficit, whether real or imagined [11]. The history must capture details of the accident, the patient’s age, occupation, leisure activities, and handedness [174]. Specific attention to documented diabetes and/or collagen vascular disease is critical [165]. A habit of smoking impacts both clinical presentation and management [165]. Medical management of diseases with pharmacologic agents may mitigate some symptoms, particularly in patients with Raynaud appearance [165].

Physical Examination¶

A careful physical examination is essential to direct care and future testing if indicated [11]. Given the density of structures in a small space, a systematic approach is required [11]. Clinicians may organize the examination by anatomic location or region of the hand, or proceed by organ system or pathology [11]. The examination should pay close attention to the appearance of the hands and the color of the fingers, looking for evidence of ischemia and/or gangrene or ulceration [165]. The warmth of the fingers is important in the physical examination [165]. Sensation plays a role in the examination, with the potential for sympathetic overactivity in the presence of nerve compression [165]. The pulses at the elbow and wrist should be felt during the physical examination [165].

Doppler ultrasound plays a very important role in the examination of the patient with a vascular disorder [165]. An Allen test can be done, however performing a similar exam with the pencil Doppler may yield much more information [165]. The arch is located with the Doppler, and the radial and ulnar arteries are compressed sequentially at the wrist [165]. The Doppler can be moved over the arch as necessary to follow the signal, listening for a change in character or flow [165]. An arterial signal should be heard with the Doppler placed on the pulp of the finger; if it is not, there is a significant problem with flow to that finger [165]. The presence of an audible Doppler arterial signal in one of the wrist’s vessels is not an indication of adequate nutritional flow to the hand [165].

The neurovascular status of the limb should be carefully evaluated and documented before surgical intervention [21]. The wound should be handled only for removal of gross contaminants, for photographic documentation, and to seal it from the environment [21]. Thorough assessment is important in the initial examination because deeper injuries are often poorly disclosed [174]. The initial examination should assess circulation, soft-tissue cover, bones, joints, nerves, and tendons [174].

Diagnostic Testing¶

Diagnostic tests such as imaging and serum laboratory studies are useful in determination but can be expensive, time consuming, and often nonspecific [11]. Computed tomography angiography (CTA) or arteriography is preferred for planning a surgical procedure when office Doppler examination is inadequate [165]. Magnetic resonance angiography (MRA) detail in many images is inadequate in terms of knowing exactly where and how significant the problem is [165]. Digital subtraction angiography (DSA) remains the gold standard for vascular evaluation [165]. Surgeons must view the vascular studies themselves because the radiologist or vascular specialist may or may not see the lesion [165]. Color-flow ultrasonography can show real-time flow and be used to evaluate an anastomosis, but is of primary use in the venous system [165].

Cold stress testing gives a measure of the vascular system’s ability to recover from exposure to cold [165]. In cold stress testing, digital temperature is measured at baseline and the hand is then placed in cold water (5° to 8°C) for 5 minutes [165]. Thermistor probes or laser Doppler are used to measure the time required for digital rewarming to baseline [165]. A prolonged rewarming response is often seen in women and can be diagnostic of Raynaud’s [165]. Smokers often have a delayed rewarming response [165]. The digital-brachial index is the ratio of the blood pressure as measured in the brachial artery and the finger [165]. In the upper extremity, a digital-brachial index value below 0.7 is felt to designate a significant occlusive problem somewhere in the forearm or hand [165].

Blood flow in the capillary bed can be measured by laser Doppler flowmetry, which can give a quantitative measurement of blood flow at skin level [165]. Laser Doppler flowmetry can be a useful tool to evaluate the results of treatments, particularly for vasospastic problems [165]. Laser Doppler flowmetry equipment is quite expensive and not available to most practitioners [165]. Nail fold capillaroscopy shows morphology and flow at the capillary level but is not of practical use for most surgeons [165]. Many sophisticated tests are difficult for the practicing surgeon to perform and do not add much to decision making in terms of patient management [165]. Sophisticated tests can be useful in determining the quality of the outcomes of management [165].

Investigations¶

Clinical Evaluation¶

Clinical evaluation of the injured or dysfunctional hand and wrist is a daunting task due to the requirement for seamless integration of joints, muscles, and nerves for painless and full function [11]. The clinician must combine patient history with a careful physical examination to pinpoint or narrow the scope of possible pathologic processes [11]. Diagnostic tests such as imaging and serum laboratory studies are useful in determining pathology but can be expensive, time consuming, and often nonspecific [11]. A systematic method to approaching the physical examination of the hand and wrist is essential due to the number of structures in a small space [11]. Clinicians may organize their examination by anatomic location or region of the hand, or by organ system or pathology [11].

Imaging¶

Doppler: An 8-MHz Doppler tone assessment may be used to identify superficially displaced neurovascular bundles when Dupuytren cords lie beneath soft fleshy prominences [128]. False-negatives are possible with 8-MHz Doppler tone assessment for identifying neurovascular bundles in Dupuytren's disease [128]. Doppler imaging is a promising improvement for identifying palmar structures, but higher resolution imaging technology is needed [128].

MRI: MR assessment of Dupuytren's disease is hindered by the resolution of current equipment, orientation issues due to multiplanar deformities of the fingers, and lack of intraoperative availability [128]. MRI is probably most useful in identifying additional pathology such as flexor tendon bowstringing in Dupuytren's disease [128]. MRI may be helpful in providing a quantitative noninvasive measure of cellularity of affected areas in Dupuytren's disease, which is an index of biologic activity [128]. High-resolution MRI is a reliable method of characterizing the anatomy of structures involved in proximal interphalangeal fracture-dislocations and could be a useful clinical tool in determining reconstructive options [133]. MRI identified the cartilaginous configuration precisely in Wassel Type IV duplicated thumbs, which assisted in choosing the correct site to perform osteotomies and eliminated the need for secondary operations [213]. Magnetic resonance imaging indicates that the donor site of autologous osteochondral mosaicplasty for cartilaginous lesions of the elbow joint is resurfaced with fibrous tissue [206]. Prolonged viability of retrograde radial fascial forearm flap tissue has been verified by magnetic resonance imaging scanning and gadolinium perfusion studies [235]. Revascularization of the trapezium treated with a vascularized distal radius bone graft was achieved as shown by MRI 12 months after surgery [217]. The use of vascularized pedicled bone grafts for disorders of the carpus has allowed for MRI evidence of revascularization of Kienböck's disease [214].

Radiography and Nuclear Medicine¶

Plain radiography: Radiographs and three-phase bone scans showed union of the iliac bone block and the stump without any resorption in all three patients undergoing composite osteocutaneous groin flap combined with neurovascular island flap for thumb reconstruction [207]. X-ray showed neither recurrence of tumour nor resorption of the fibular graft in a case of en bloc excision and reconstruction with a fibular autograft of giant-cell tumour of the metacarpal [208]. Radiographs showed complete incorporation of the graft with normal bone healing and an appropriate joint space without signs of cartilage necrosis or degradation in a case of proximal interphalangeal joint repair with a homograft [211]. A comparative analysis of the immediate and final radiographs of a bone block graft from the iliac crest showed an average 30% loss of bone mass despite integration [225]. Eight years after surgery, x-ray and clinical examination revealed no evidence of instability or material failure in a case of segmental metacarpal replacement with bone cement and a silicone joint prosthesis [237]. There was no angular deformity of the grafts nor radiographic evidence of resorption or aseptic necrosis of the grafted bone at the time of the final evaluation in finger joint reconstruction with costal osteochondral graft [252]. Follow-up at 2 years after surgery for a costal cartilage graft for an unstable post-traumatic trapeziometacarpal intra-articular malunion in a pediatric patient showed excellent clinical and radiological results [59].

Treatment¶

General Principles and Planning¶

Reconstructive decision making in the elbow, wrist, and hand relies heavily on surgeon experience and popular consensus rather than high-quality evidence [1]. The primary goal in managing a mangled upper extremity is to preserve life [35]. The quality of wound débridement dictates the outcome of limb salvage [35], and successful reconstruction is largely based upon the outcomes of the initial surgical treatment, which is dependent on the adequacy of débridement [127]. Critical aspects of successful reconstruction include complete debridement of devitalized tissue, restoration of good vascularity, early rigid skeletal fixation while minimizing additional tissue injury, and stable, vascularized soft tissue coverage [113]. The goals of treatment for mangled injuries are to preserve life, preserve viable tissue, preserve function, and reconstruct and restore function of the extremity [113]. Thoughtful staged surgical planning is necessary to avoid limiting surgical options for reconstruction [35].

The "one wound–one scar" concept describes how a scar forms from the skin down through bone, compromising the function of all structures involved and the extremity overall [130]. Adherence to principles including complete debridement, restoration of vascularity, rigid skeletal fixation, stable vascularized soft tissue coverage, timely intervention, comprehensive rehabilitation, and secondary procedures allows for early mobilization and minimizes the impact of scarring [130]. The decision to amputate or salvage a severely injured extremity relies on the expertise of the orthopedic surgeon and input from subspecialty colleagues such as general trauma, vascular, and plastic surgeons [136]. Limb salvage scores have proved to have little clinical utility in determining whether to reconstruct or amputate an extremity [136]. Current data suggest that the results of limb reconstruction are equal to those of amputation following severe lower extremity trauma [136]. Amputation is a reconstructive procedure that should provide the patient with the best possible residual limb to form a robust foundation for prosthesis fitting and return of optimal function [139]. Early plastic surgery involvement from the trauma room improved outcomes and reconstruction planning [32]. The success of reconstructive surgery relies not only on the technical achievement by the surgeon but also on a functional improvement [31]. The surgical indication and rehabilitation are very important factors in the outcome of functional surgery for the tetraplegic upper limb [44].

Pediatric Considerations¶

The decision regarding which children can be helped by surgical reconstruction, at what age it should be carried out, and which operative procedure would be appropriate is the critical challenge for pediatric hand surgeons [12]. Factors to consider before embarking on reconstruction in children include the child’s variable and often limited ability to cooperate in the postoperative period, the risk associated with anesthesia in early life, the size of the structures, absence of critical parts, the need for growth, and occasionally the reduced life span of some patients with particular congenital syndromes [12]. The goal of pediatric hand surgery is to get the best result with the least insult to the limb because the healing capacity of the tissues is compromised by repeated operations [12]. Treatment of congenital upper extremity disorders requires an understanding of the classification system used to categorize each disorder to educate the patient and family regarding anatomic differences and potential treatment options [125]. Not all deformities require surgery, and each child and their function must be taken into consideration separately, often observing the child as they grow before creating a definitive treatment plan [125]. Occupational therapy and/or hand therapy are often vital to the function and postoperative recovery of the child’s upper extremity who is born with a congenital difference [125].

Microvascular toe transfer in children is justified for most surgeons only if substantial functional gain ensues [277]. The aesthetic considerations in a child are very important because the hand is constantly on view and can be the focus of teasing [277]. Mirror hand-ulnar dimelia typically involves the entire upper limb, and treatment plans should consider predictors of function at each limb segment rather than just morphology [62].

Soft Tissue Coverage and Flaps¶

Combined reconstruction strategies should be considered based on defect characteristics, with acceptable complication rates and good functional recovery [4]. Free flap reconstructions offer critical advantages over non-microsurgical techniques, including early mobilization and appropriate coverage with acceptable donor morbidity [17]. Optimal functional and aesthetic outcomes depend on optimizing flap selection based on patient body habitus, anatomic location, and defect characteristics, while utilizing adjuncts like suprafascial harvest and meticulous inset to minimize donor site morbidity [39]. Secondary free flap reconstruction delays rehabilitation, prolongs hospital stay, and increases overall costs and number of operations, although the initial operative time is shorter [21]. A serial approach to debridement may be indicated in the unusual circumstance in which conversion of a contaminated wound to a cleaner wound is impossible, such as after severe crush injuries, severe multiplanar degloving, massive wound contamination, electrical burn injuries, or in patients with other life-threatening injuries that preclude a surgical procedure of required duration [21].

The method of soft-tissue reconstruction has no effect on functional outcome in interscapulothoracic resection of tumours of the shoulder [42]. The use of the superficial flexor synovial flap for palmar defects should remain limited to cases where commonly used flaps are contraindicated or unusable, and larger series are needed to validate its indications [34]. The success rate of local flaps in the management of deep finger burns was 84% [120]. Early venous congestion is common in venous flaps for coverage of traumatic soft tissue defects of the hand, but can be managed non-operatively [269]. The modified reverse flow shunt restricted arterialized venous free flap technique resulted in high flap survival rates with satisfactory functional outcomes in a clinical series of 9 cases [122]. The ulnar artery distal cutaneous descending branch free flap provided satisfactory reconstruction of hand wounds with 100% flap survival and acceptable aesthetic and functional results in a series of 79 flaps [110]. The free ‘mini’ groin flap is recommended for digital resurfacing specifically in moderate to large dorsal defects, proximal volar defects, circumferential skin loss, and multiple digit injuries [291]. The dorso-ulnar osteocutaneous reverse flow flap of the thumb is useful for the reconstruction of distal osteocutaneous defects of the thumb where more complex procedures are not feasible or considered as excessive [137]. The reversed vascularized pedicled forearm flap provides adequate soft tissue and good functional outcome compared with other salvage procedures for complete degloved digits [117]. One-stage reconstruction of donor site defects using artificial dermis represents an effective and clinically viable treatment option given its low donor-site morbidity and favorable cosmetic and functional outcomes [118].

The reconstructive elevator concept suggests that consideration of coverage can proceed based on what would provide the most functional and cosmetic outcome, rather than a step-wise fashion, as the simplest solution is not necessarily the best solution [290]. Negative pressure wound therapy (NPWT) can help build a layer of granulation tissue over structures that would have precluded immediate skin grafting, such as tendon or bone [290]. Healing by secondary intention is not advised in the presence of exposed nonvascularized structures such as bone, hardware, and tendons [258]. Secondary healing of small wounds over muscle or fascia may be appropriate, especially if the medical status does not permit more complex reconstruction methods [258].

Digital and Fingertip Reconstruction¶

Patients with firework-related hand injuries often require reconstruction rather than repair, and many will require secondary procedures, making prevention the best treatment [2]. The homodigital neurovascular island flap is a safe and reliable flap with satisfactory patient-reported outcome measures and objective outcomes at long-term follow-up [16]. The reconstruction using parallelogram flaps is an easier and more versatile treatment with better functions, less morbidity, and better aesthetics compared to homodigital island flaps for fingertip defects with bone exposure [123]. Methods of reconstruction without skin grafts for digital syndactyly release have recently been described and outcomes are generally good [116]. The non-vascularised fibular graft was an effective solution for radius reconstruction in a series of four cases [209]. No conclusive evidence exists in favor of an immediate versus a primary, early or delayed emergency reconstruction for post-traumatic finger reconstruction via toe-to-hand transfer [273]. The combination of salvage microsurgical procedures with non-microsurgical methods, such as pinch reconstruction by hand-to-hand finger transfer associated with hallux transfer, can provide a satisfactory functional result [236].

Thumb and Wrist Reconstruction¶

Different microsurgical transfer techniques for thumb repair and reconstruction suggest a great freedom of surgical choices, but choices are considerably restricted if all functional and cosmetic requirements are to be met [20]. The alternative method for thumb reconstruction combining metacarpal lengthening and mini wraparound transfer is mainly chosen by selected patients who refuse standard microsurgical thumb reconstruction because it requires a longer treatment period [48]. Although the Krukenberg procedure is considered obsolete by many surgeons due to appearance, non-medical people do not consider the unattractive appearance to outweigh the functional outcome [41]. The modified Viegas dorsal capsuloplasty is a treatment option for chronic partial scapholunate ligament lesions in young athletes, though it carries the expectation of some limitation of wrist movement and loss of grip strength [284]. The reconstruction of the extensor carpi ulnaris subsheath using a fascia lata allograft is indicated when conservative treatment is inadequate [261]. The metacarpophalangeal joint extensor tendon subluxation reconstructive stabilization technique offers a simple, effective, and strong repair with minimal donor site morbidity and a good prognosis for recovery [126].

Tendon and Nerve Reconstruction¶

Current indications and methods for secondary flexor tendon reconstruction, including delayed treatment and 1-stage and 2-stage reconstruction, are reviewed with future directions discussed [3]. The advantages of increased safety and a consistently good functional outcome warrant adding staged opposition transfer to the armamentarium of the reconstructive hand surgeon [19]. The toe-to-finger free flexor tendon transfer is a technique for digital flexion reconstruction with specific indications and advantages [143]. Published clinical results have demonstrated significant improvements in upper limb function for the contralateral C7 transfer, confirming the procedure's safety and efficacy, with donor site morbidity that is typically mild and transient [108]. Reconstructive surgery for upper extremity deformities in spastic cerebral palsy produced significant functional improvements at 6 months which remained essentially unchanged at the 4.5-year follow-up [8]. The six-strand double-loop technique for flexor tendon repair in Zone II appears better without an increased rate of rupture but with a shorter rehabilitation period compared to a two-strand technique [223]. If conservative measures have failed and operative treatment is undertaken for simple camptodactyly, a programme of early post-operative mobilisation, together with static and dynamic splinting, is recommended to minimise the loss of flexion [240]. Long-term results following soft tissue reconstruction for Boutonniere finger deformity in rheumatoid arthritis are unreliable, and recurrent or persistent deformity is best treated with a salvage procedure [5]. The patients' lack of interest in having the thumb salvaged or reconstructed for rodeo roping injuries was almost unanimous [219].

Replantation¶

Replantation is indicated for severed thumbs or multiple digits, transmetacarpal hand amputations, wrist- or distal forearm-level amputations, and amputations of almost any body part in a child [135]. Contraindications to replantation include severely crushed or mangled parts; multilevel amputation; amputations in patients with arteriosclerotic vessels; amputations in patients with other serious injuries or diseases; and amputations with prolonged warm ischemic times, particularly at proximal levels [135]. In adults, replantation of a single finger proximal to the insertion of the flexor digitorum superficialis is usually contraindicated because of the poor functional outcome due to stiffness [135]. Replantation at the level proximal to the insertion of the flexor digitorum superficialis may be considered in children or for aesthetic reasons [135].

The preferred method of anesthesia for replantation is axillary or supraclavicular block because this technique provides a sympathetic block resulting in vasodilation [135]. The surgical sequence of replantation begins with wide surgical exposure, meticulous debridement, bone shortening and secure internal fixation, repair of extensor tendons, repair of flexor tendons, anastomosis of one or preferably two arteries, repair of nerves, and anastomosis of veins [135]. Two veins should be repaired for each artery repaired during replantation [135]. In replantations proximal to the distal forearm, fasciotomies of all muscle compartments should be performed at the time of replantation [135]. The patient undergoing proximal replantation should be returned to the operating room in 48–72 hours so the wound may be reevaluated and any additional necrotic tissue debrided [135]. Anticoagulation should be given in the perioperative period to diminish the likelihood of anastomosis thrombosis, with low-molecular-weight dextran for 5–7 days and aspirin among the recommended regimens [135]. Vasospastic agents such as nicotine, caffeine, theophylline, and theobromine should be restricted for the first few weeks after replantation or revascularization [135]. The patient should be placed on a broad-spectrum antibiotic for 5–7 days postoperatively [135]. If failure of a replanted part appears secondary to poor venous outflow, the intermittent application of leeches for 1–5 days may provide transient venous drainage while adequate venous drainage is reestablished [135]. Vascular revision is most successful when carried out within 48 hours of injury [135].

Approximately 85% of replanted parts remain viable [135]. Sensory recovery with two-point discrimination of 10 mm or less occurs in approximately 50% of adults after replantation [135]. Patients with viable replanted or revascularized parts often complain of cold intolerance during the first 2 or 3 years after replantation [135]. While microsurgery has made replantation a routine procedure with reliable viability rates, achieving a satisfactory functional result is difficult and depends on a variety of factors [112]. Experience dictates that satisfactory functional results in replantation can be achieved only if the basic principles and indications of replantation surgery are adhered to [49]. A vein interposition graft from the digital artery to the radial artery within the anatomic snuff box can facilitate thumb replantation or revascularization [35].

Specific Conditions and Deformities¶

Five years after successful collagenase Clostridium histolyticum (CCH) treatment for Dupuytren contracture, the overall recurrence rate of 47% was comparable with published recurrence rates after surgical treatments, with one reported long-term treatment-related adverse event [46]. There is low level of evidence that both surgical and nonsurgical treatments provide clinically important improvements for recurrent Dupuytren contracture [226]. Nonsurgical treatment options used for pathological scars and skin management techniques in surgical scar revision are also routinely applied in Dupuytren's disease [233]. The article highlights advancements in surgical and therapy management for Dupuytren's disease, reviewing indications, surgical options, non-surgical techniques, and therapy interventions to assist in linking patient-specific problems to appropriate treatment choices [192].

We were unable to recognize a substantial clinical or radiological difference between radial shortening osteotomy and vascularized bone graft in long-term outcome for Kienböck disease [25]. Transplantation of allografts for the treatment of intercalary defects has a high rate of success and usually results in a functional limb, despite the relatively high rate of non-union that necessitated additional operations [239]. Multidisciplinary management is essential to prevent retractive sequelae of palmodigital burns, and Z-plasties and Trident flaps remain the most effective and least traumatic options, especially in children [275]. Splinting should continue until re-epithelialization is complete after hand burn surgery for maintained prevention of edema, contracture, scarring, and functional impediment [259]. Early and aggressive hand physical therapy and rehabilitation are critical to the success of most surgical interventions for hand burns [259]. Contracture of the skin, fascia, and/or muscles is the most common postburn hand deformity and can severely impede recovery [259]. Flexion contractures should be released before extension contractures to prevent the burying of fingers into the palm and to improve hygiene [259]. After contracture release, split-thickness skin graft (STSG) alone provides reliable coverage and significant range of motion improvement, especially dorsally, whereas chronic volar contractures are more likely to require flap closure to cover critical structures [259]. In the first webspace, local flap management has been shown to require fewer revision procedures than skin grafting [259]. Chronic boutonniere deformity can often retain basic functionality and is passively correctable with splinting; furthermore, invasive procedures often

Complications¶

General and Decision-Making: Reconstructive decision making in elbow, wrist, and hand surgery relies on surgeon experience and popular consensus rather than excellent evidence [1]. Because trauma is usually a precursor, reconstructive surgery can seldom be standardized; surgeons must be aware of all possible approaches to ensure the safest results [6]. The healing capacity of tissues is compromised by repeated operations [12]. Failure to take preoperative photographs, measure and record joint angles and grip strength, and perform functional tests before treatment renders an honest, accurate assessment of the result at the end of treatment impossible [12]. Adult reconstructive surgery has evolved significantly with high success rates for joint disorders, though cumulative failure rates remain approximately 1% per year, resulting in a 90% success rate at 10 years [234].

Microsurgical and Flap Complications: Microsurgical complications may take the form of complete or partial flap necrosis or loss of a revascularized or replanted part [229]. Most microsurgical failures can be attributed to errors in preoperative planning and patient preparation, intra-operative patient management and technical execution, and post-operative patient management [229]. The risk of adverse events for local flap reconstruction for digital soft tissue defects is acceptable in all flap types, with an overall rate of 5.4% [23]. Reoperations are needed in approximately 2% of cases for local flap reconstruction for digital soft tissue defects [23]. In a series of 123 lateral arm flaps, 35 complications were reported in the early post-operative period, affecting 28 of the flaps (22.7%) [218]. Reoperation was required for vascular occlusion in 14 cases (11.4%) of lateral arm flaps [218]. Of the 14 cases requiring reoperation for vascular occlusion in lateral arm flaps, 8 were successfully salvaged (57%) [218]. A total of eight flaps suffered at least partial necrosis (6.6%) in a series of 123 lateral arm flaps [218]. In five cases of lateral arm flap complications, there was complete loss of the flap (4.0%) [218]. In three patients (2.6%) with lateral arm flaps, the necrosis involved only part of the flap [218]. Six deep infections (4.9%) occurred in a series of 123 lateral arm flaps [218]. Loss of skin grafts placed over fascial extensions of the fasciocutaneous flap occurred in five cases (4.6%) of lateral arm flaps [218]. Necrosis of skin grafts placed on donor sites occurred in two patients (5%) of a series of 40 donor sites for lateral arm flaps [218]. In the opinion of individual patients, 29 of the donor sites (26.6%) for lateral arm flaps were unsatisfactory from a cosmetic standpoint [218]. The difference in the incidence of dissatisfaction with donor site appearance between primary closure and split-thickness skin graft coverage for lateral arm flaps was not statistically significant [218]. In less-experienced hands, omission of primary closure of the donor site in VY-plasty may prevent iatrogenic flap ischemia [253]. Venous congestion was observed in two flaps during modified pivot flap reconstruction of fingertip defects, with one resolving spontaneously and the other developing superficial partial flap necrosis treated conservatively [262]. All flaps survived without major complications in a series of glabrous palmar flaps [52]. All flaps survived in a series of microsurgical free lateral great toe flaps for revision of residual deformities after primary surgery for Wassel-Flatt IV-D thumb duplication [58]. The donor foot does not suffer functionally in long-term follow-up of up to six years after finger reconstruction using toe transplantation [47]. The thumb can be restored nearly to original condition with acceptable donor site sequela after onycho-osteocutaneous defects reconstructed by partial toe to hand transfer [263].

Specific Procedure Complications and Outcomes: Approximately 13% of syndactyly reconstructions require reoperation, with most occurring within 4 years of the primary procedure [264]. Long-term results after surgical reconstruction for radial polydactyly were excellent but the revision rate trended upward over time despite maintenance of favorable scores on objective outcome measures [53]. The procedure for basal joint resection arthroplasty of the thumb with transfer of the abductor pollicis brevis origin to the flexor carpi radialis tendon is safe, with a low complication rate, and demonstrates long-term durability [129]. Longer follow-up and prospective randomized comparisons are needed to better define rates of revision, failure, and complications for proximal interphalangeal joint prosthetic arthroplasty [131]. There appears to be no benefit to tendon interposition or ligament reconstruction in the longer term for trapeziometacarpal osteoarthritis [164]. Five years after successful collagenase clostridium histolyticum treatment for Dupuytren contracture, the overall recurrence rate was 47%, comparable with published recurrence rates after surgical treatments, with one reported long-term treatment-related adverse event [46]. Limb salvage for extremity sarcomas has higher rates of postoperative complications, including infection, aseptic loosening, and graft or prosthetic failure, compared to amputation [171]. Complication rates reported after free vascularized fibular graft reconstruction remain high (37%–80%), although the frequency of the different complications varies widely [254]. Vascularised fibular grafts for reconstruction of extremity bone defects are associated with a relatively high rate of complications, with a high rate of successful limb salvage and a good long-term functional outcome [51]. Intermediate-term outcomes for arterial grafts in upper extremity vascular reconstruction are promising, with patency rates up to 100% reported, though no long-term outcomes studies exist [57]. Patients with firework-related injuries of the hand often require reconstruction rather than repair, and many will require secondary procedures [2]. The long-term outcomes of arthrodesis for severe recurrent proximal interphalangeal joint contractures in Dupuytren’s disease show high patient satisfaction, fairly rapid return to function with no requirement for revision surgery [54]. Syndactyly reconstruction yields satisfactory subjective long-term outcomes [55]. At a long-term follow-up, the patient-reported outcome measures and objective outcomes of the homodigital unipedicle neurovascular island flap are satisfactory and it is a safe and reliable flap [16]. Combined reconstruction strategies for severe hand injuries using posterior interosseous artery flaps have acceptable complication rates and good functional recovery [4]. The cross-finger flap for reconstruction of fingertip amputations is a simple, reliable, long-lasting reconstruction technique [24].

Recovery¶

General Principles and Timing: Early or immediate complete upper extremity reconstruction yields better results than delayed or late reconstruction and should be the treatment of choice where possible [66]. Early microsurgical reconstruction following radical debridement significantly lowers postoperative morbidity, infection rate, and the number of subsequent procedures compared with delayed or late operations [296]. In post-traumatic upper limb reconstructive microsurgery, early aggressive debridement and immediate all-in-one reconstruction offer the best functional results [64]. For hand burns, the mean time to the first reconstructive surgery was 20 months (SD 20; range 4–118 months) [65]. Most reconstructive surgeries after hand burns were performed within the first 2 years (55%), with 19.1% within the first year and 35.8% between the first and second year [65]. Fourteen percent of reconstructive surgeries after hand burns were performed at least 5 years after the injury [65]. In Zone 2 flexor tendon injuries, the time elapsed between injury and surgery is not an important risk factor for a good outcome; rather, outcomes depend on proper surgical methods, the surgeon's experience, and early mobilization [283]. A patient should not be denied reconstructive microvascular surgery solely because of advanced calendar age [63].

Specific Procedures and Outcomes: Long-term patient-reported outcome measures and objective outcomes of the homodigital unipedicle neurovascular island flap for fingertip coverage are satisfactory, and it is a safe and reliable flap [16]. Vascularised fibular grafts for reconstruction of extremity bone defects are associated with a relatively high rate of complications, but each reconstruction method is useful with a high rate of successful limb salvage and a good long-term functional outcome [51]. Long-term outcomes of arthrodesis for severe recurrent proximal interphalangeal joint contractures in Dupuytren’s disease show high patient satisfaction and fairly rapid return to function with no requirement for revision surgery [54]. In the revision of residual deformities after primary surgery for Wassel-Flatt IV-D thumb duplication using a microsurgical free lateral great toe flap, all flaps survived, and patients followed up for 8–12 months showed satisfactory appearance [58]. Follow-up at 2 years after costal cartilage graft for an unstable post-traumatic trapeziometacarpal intra-articular malunion in a pediatric patient showed excellent clinical and radiological results [59]. The superficial flexor tendon flap technique for median nerve neuromas should be completed by MRI studies to objectively follow the evolution of the flap [61]. Fifteen-month follow-up after reconstruction of a hand amputated at the metacarpophalangeal level by means of combined second and third toes from each foot showed acceptable cosmesis with satisfactory functional results [152]. Five months follow-up after reconstruction of a digitless hand showed satisfactory functional recovery and cosmetic results [162]. Follow-up studies of up to 10 years after completion of treatment using the bone-lengthening method in hand reconstruction showed a good function of the reconstructed thumbs and fingers without trophic changes and with preserved sensibility on the whole surface [163]. Long-term follow-up of free vascularized fibular graft for congenital pseudarthrosis of both forearm bones permits noting a good morphologic integration and adaptation of the graft in the forearm [166]. Long-term follow-up results show that patients with toe-to-hand transfers have acceptable adaptation to the reconstructed hand and good hand function [167]. The long-term outcome of reconstruction of the proximal half of the radius using vascularized fibula should be monitored to determine the definitive role of the vascularized fibula for replacement of the proximal radius [173]. The minimum duration between stage I surgery and stage II surgery in staged flexor tendon reconstruction increased from 6 weeks early in the series to 3 months currently [289]. The time required for healing of the great-toe defect after wrap-around toe transfer with a free lateral forearm flap was less than 1 month, and all patients were satisfied with the outcome [292]. The selection of a free flap procedure for pain relief after Adriamycin necrosis on the dorsum of the hand allowed a relatively short one-session procedure and a short period in hospital [293]. The duration of banking before secondary thumb reconstruction via ectopic banking of bony phalanges should be no more than 2 weeks [295]. Better timing of the procedure and progressive experience gained by one surgeon using the same procedure are attributed to improved outcomes in the treatment of syndactyly [297].

Key Evidence¶

[L4] Reconstructive decision making is based on surgeon experience and popular consensus rather than excellent evidence. [1] (10.1016/j.hcl.2013.04.010)
[L4] Patients often require reconstruction rather than repair, and many will require secondary procedures, making prevention the best treatment. [2] (10.1016/j.jhsa.2014.08.041)
[L5] Current indications and methods, including delayed treatment and 1-stage and 2-stage reconstruction, are reviewed with future directions discussed. [3] (10.1016/j.jhsa.2007.08.018)
[L4] Combined reconstruction strategies should be considered based on defect characteristics, with acceptable complication rates and good functional recovery. [4] (10.1016/j.injury.2026.113151)
[L5] Long-term results following soft tissue reconstruction are unreliable, and recurrent or persistent deformity is best treated with a salvage procedure. [5] (10.1016/j.jhsa.2011.05.029)
[L5] Reconstructive surgery can seldom be standardized, since trauma is usually a precursor, and surgeons must be keenly aware of all possible approaches to ensure the safest and most satisfactory results. [6] (10.1016/s0363-5023(81)80002-0)
[L4] The aim of surgical treatment is to try to reconstruct or correct the anatomic difference and at the same time provide a more acceptable appearance. [7] (10.1097/00130911-200412000-00008)
[L4] Reconstructive surgery produced significant functional improvements at 6 months which remained essentially unchanged at the 4.5-year follow-up. [8] (10.1054/jhsb.1999.0265)
[L4] Complete identification of pathologic structures and anatomic reconstruction is the cornerstone of successful surgical treatment. [13] (10.1016/s0363-5023(98)80081-6)
[L5] The concept of the 'reconstructive elevator' allows surgeons to choose more complex reconstructions to account for specialized function and aesthetic outcomes, rather than adhering strictly to the simplest technique. [15] (10.1016/j.jhsa.2016.04.020)
[L4] At a long-term follow-up, the patient-reported outcome measures and objective outcomes of this flap are satisfactory and it is a safe and reliable flap. [16] (10.1177/17531934231172081)
[L4] Free flap reconstructions offer critical advantages over non-microsurgical techniques, including early mobilization and appropriate coverage with acceptable donor morbidity. [17] (10.1016/j.injury.2013.01.021)
[L5] A thorough understanding of the complex anatomy and a working knowledge of the reconstructive options available are essential for successful outcomes. [18] (10.5435/jaaos-d-18-00218)
[L4] The advantages of increased safety and a consistently good functional outcome warrant adding this technique to the armamentarium of the reconstructive hand surgeon. [19] (10.1016/s0363-5023(98)80129-9)
[L4] Different microsurgical transfer techniques suggest a great freedom of surgical choices, but choices are considerably restricted if all functional and cosmetic requirements are to be met. [20] (10.1177/1753193417723310)
[L5] [21] (10.1016/j.hcl.2014.01.001)
[L5] Essentially there are currently no criterion standard measures to evaluate the consequences of reconstructive arm/hand surgery. [22] (10.1016/j.apmr.2015.10.110)
[L1] The risk of adverse events is acceptable in all flap types, with an overall rate of 5.4% and reoperations needed in approximately 2% of cases. [23] (10.1016/j.hcl.2019.08.009)
[L4] This is a simple, reliable, long-lasting reconstruction technique. [24] (10.1016/j.otsr.2016.03.006)
[L3] We were unable to recognize a substantial clinical or radiological difference between the 2 surgical treatments in long-term outcome. [25] (10.1016/j.jhsa.2012.11.016)
[L5] The authors propose a classification system for hand soft-tissue defects based on size, location, and tissue characteristics to guide flap selection. [29] (10.1016/j.hcl.2017.04.001)
[L4] The elegance of this reconstructive surgery is the ability to tailor the particular operation to a specific injury pattern and patient type. [30] (10.1016/j.injury.2013.01.027)
[L4] The success of reconstructive surgery relies not only on the technical achievement by the surgeon but also on a functional improvement. [31] (10.1016/0266-7681(86)90002-1)
[L4] Early plastic surgery involvement from the trauma room improved outcomes and reconstruction planning. [32] (10.1016/j.injury.2026.113720)
[L5] However, its use should remain limited to cases where commonly used flaps are contraindicated or unusable, and larger series are needed to validate its indications. [34] (10.1016/j.main.2013.09.001)
[L5] The main element of treatment consists in a wide surgical resection, and flap reconstruction surgery can be proposed in distal locations. [37] (10.1016/j.main.2013.08.003)
[L4] [38] (10.1016/0266-7681(86)90006-9)
[L5] Optimal functional and aesthetic outcomes depend on optimizing flap selection based on patient body habitus, anatomic location, and defect characteristics, while utilizing adjuncts like suprafascial harvest and meticulous inset to minimize donor site morbidity. [39] (10.1016/j.hcl.2014.01.005)
[L4] Although considered obsolete by many surgeons due to appearance, non-medical people do not consider the unattractive appearance to outweigh the functional outcome. [41] (10.1177/1753193411406479)
[L4] The method of soft-tissue reconstruction has no effect on functional outcome. [42] (10.1302/0301-620x.96b5.32241)
[L5] The surgical indication and rehabilitation are very important factors in the outcome. [44] (10.1016/j.hansur.2020.05.012)
[L4] [45] (10.1016/0363-5023(91)90176-c)
[L2] Five years after successful CCH treatment, the overall recurrence rate of 47% was comparable with published recurrence rates after surgical treatments, with one reported long-term treatment-related adverse event. [46] (10.1016/j.jhsa.2015.04.036)
[L4] The donor foot does not suffer functionally in long-term follow-up of up to six years. [47] (10.1016/0266-7681(86)90005-7)
[L4] This procedure is mainly chosen by selected patients who refuse standard microsurgical thumb reconstruction because it requires a longer treatment period. [48] (10.1016/j.jhsa.2013.02.030)
[L5] Experience dictates that this can be achieved only if the basic principles and indications of replantation surgery are adhered to. [49] (10.1054/jhsb.2001.0595)
[L4] The procedure is recommended only as a salvage procedure. [50] (10.1016/j.jhsa.2020.06.001)
[L4] Although associated with a relatively high rate of complications, each reconstruction method is useful, with a high rate of successful limb salvage and a good long-term functional outcome. [51] (10.1302/0301-620x.99b9.bjj-2017-0219.r1)
[L4] The postoperative course was uneventful, and all the flaps survived without major complications. [52] (10.1097/bth.0b013e3181ac9183)
[L4] Long-term results after surgical reconstruction for radial polydactyly were excellent but the revision rate trended upward over time despite maintenance of favorable scores on the objective outcome measures used. [53] (10.1016/j.jhsa.2014.05.006)
[L4] The long-term outcomes show high patient satisfaction, fairly rapid return to function with no requirement for revision surgery. [54] (10.1177/1753193420960309)
[L4] Syndactyly reconstruction yields satisfactory subjective long-term outcomes. [55] (10.1177/17531934251380997)
[L5] Compared with no reconstruction, any procedure is of benefit. [56] (10.1016/j.jhsa.2016.09.012)
[L4] Intermediate-term outcomes for arterial grafts in upper extremity vascular reconstruction are promising, with patency rates up to 100% reported, though no long-term outcomes studies exist. [57] (10.1016/j.jhsa.2012.12.009)
[L4] All flaps survived and patients were followed up for 8–12 months with satisfactory appearance of the reconstructed thumbs. [58] (10.1177/17531934231222400)
[L5] Follow-up at 2 years after the surgery showed excellent clinical and radiological results. [59] (10.1016/j.hansur.2020.10.014)
[L4] The study suggests this technique should be completed by MRI studies to objectively follow the evolution of the flap. [61] (10.1016/j.main.2009.06.007)
[L4] Mirror hand-ulnar dimelia typically involves the entire upper limb, and treatment plans should consider predictors of function at each limb segment rather than just morphology. [62] (10.1177/17531934221116960)
[L5] A patient should not be denied reconstructive microvascular surgery solely because of advanced calendar age. [63] (10.1016/s0363-5023(86)80241-6)
[L4] The article presents the experience of a single surgeon performing post-traumatic upper limb reconstructive microsurgery over 30 years, emphasizing that early aggressive debridement and immediate all-in-one reconstruction offer the best functional results. [64] (10.1177/1753193420915398)
[L4] [65] (10.1016/j.jhsa.2017.02.006)
[L5] Early or even immediate complete upper extremity reconstruction appears to give better results than delayed or late reconstruction and should be the treatment of choice where possible. [66] (10.1007/s00264-012-1638-y)
[L5] The modified evidence-based classification system corrects weaknesses of earlier systems by providing specificity for endoprosthetic, biological, and paediatric failures, allowing for better interpretation of outcomes following reconstructive surgery. [69] (10.1302/0301-620x.96b11.34747)
[L5] Blauth’s classification continues to be helpful for description of the degree of hypoplasia leading to different options of surgical reconstruction. [74] (10.1016/j.main.2006.01.001)
[L4] The proposed classification system supplements Wassel's classification by providing clear guidance on surgical methods and required surgeon expertise levels, facilitating treatment decision-making and communication. [82] (10.1177/1753193421995697)
[L4] A retrospective analysis of the results has shown the classification to be helpful in selecting a surgical option for treatment. [106] (10.1016/s0363-5023(05)80101-7)
[L5] Published clinical results have demonstrated significant improvements in upper limb function, confirming the procedure's safety and efficacy, with donor site morbidity that is typically mild and transient. [108] (10.1177/17531934251314640)
[L4] The series of 79 free flaps provided satisfactory reconstruction of hand wounds with 100% flap survival and acceptable aesthetic and functional results. [110] (10.1016/j.injury.2009.04.009)
[L5] While microsurgery has made replantation a routine procedure with reliable viability rates, achieving a satisfactory functional result is difficult and depends on a variety of factors. [112] (10.5435/00124635-199803000-00004)
[Paper] Methods of reconstruction without skin grafts have recently been described and outcomes are generally good. [116] (10.1097/bth.0b013e3181cf7d70)
[L4] This flap provides adequate soft tissue and good functional outcome compared with other salvage procedures. [117] (10.1016/j.jhsa.2012.01.032)
[L4] Given its low donor-site morbidity and favorable cosmetic and functional outcomes, one-stage reconstruction of donor site defects using artificial dermis represents an effective and clinically viable treatment option. [118] (10.1016/j.injury.2025.112450)
[L4] The success rate of the flaps was 84%. [120] (10.1016/j.hansur.2019.10.070)
[L4] The classification of ring avulsion injuries needs modification to clarify the differences between total avulsion of the soft tissue alone and avulsion with amputation. [121] (10.1054/jhsb.1999.0199)
[L4] In this clinical series of 9 cases, the modified technique resulted in high flap survival rates with satisfactory functional outcomes. [122] (10.1016/j.jhsa.2018.02.023)
[L2] The reconstruction using parallelogram flaps is a easier and more versatile treatment with better functions, less morbidity and better aesthetics. [123] (10.1186/s13018-022-03214-1)
[L4] The technique offers a simple, effective, and strong repair with minimal donor site morbidity and a good prognosis for recovery. [126] (10.1016/j.jhsa.2012.12.021)
[L4] The procedure is safe, with a low complication rate, and demonstrates long-term durability. [129] (10.1016/j.jhsa.2009.03.016)
[L4] Longer follow-up and prospective randomized comparisons are needed to better define rates of revision, failure, and complications. [131] (10.1016/j.jhsa.2010.04.005)
[L4] This report presents a classification system and four different treatment strategies based on presenting radiographs to guide the decision-making process for two-stage hand reconstruction in Apert acrosyndactyly. [132] (10.1016/s0363-5023(97)80170-0)
[L2] High-resolution MRI is a reliable method of characterizing the anatomy of these structures and could be a useful clinical tool in determining reconstructive options. [133] (10.1177/17531934231220783)
[L5] The need for refinement and secondary surgery should be taken into consideration during the initial flap selection process. [134] (10.1016/j.hcl.2014.01.004)
[L4] Even though the indications are rare, this flap is useful for the reconstruction of distal osteocutaneous defects of the thumb where more complex procedures are not feasible or considered as excessive. [137] (10.1054/jhsb.2001.0584)
[L4] The surgical procedure provides good functional outcomes and may reduce the need for prosthesis acceptance. [138] (10.1016/j.jhsa.2012.06.023)
[L2] We propose a modified classification that is a practical and utilitarian scheme for nomenclature of radial polydactyly and that may assist comparison of treatment outcomes and individual cases. [141] (10.1016/j.jhsa.2007.12.012)
[L4] Hand function after bone loss depends on maintaining length and alignment of the metacarpals and preserving joint motion. [142] (10.1016/s0363-5023(81)80164-5)
[L4] Indications and advantages of this free tendon transfer are also discussed. [143] (10.1016/s0363-5023(03)80402-1)
[L5] Continued enhancement in immune modulation, surgical indication, patient selection, and posttransplant care is expected to make VCA a major milestone in reconstructive surgery. [146] (10.1016/j.jhsa.2017.01.019)
[L5] There is a need for more detailed classification systems and agreed outcome measures to facilitate comparison of outcomes in the absence of high-level evidence. [147] (10.1177/17531934251397218)
[L4] The free TDAP flap, with five types of advanced applications, makes it versatile for reconstructing different kinds of soft tissue defects of the extremities that can be used to achieve individualized defect reconstruction, minimize donor site morbidities, and an aesthetic appearance. [148] (10.1186/s13018-023-04480-3)
[L4] The surgical procedure has evolved and been standardized to optimize the final functional result while limiting donor site sequelae. [150] (10.1016/j.main.2010.10.015)
[L5] Fifteen-month follow-up showed acceptable cosmesis with satisfactory functional results. [152] (10.1016/s0363-5023(86)80139-3)
[Paper] The present study reviews 'bypassable' upper extremity ischemia and revascularization with vein grafts and proposes a classification system for distal upper extremity bypass vein grafts. [157] (10.1097/00130911-199906000-00009)
[L5] Surgical intervention should follow the standard reconstructive ladder and can involve several techniques from simple to complex. [159] (10.1016/j.hcl.2016.12.006)
[L5] Five months follow-up showed satisfactory functional recovery and cosmetic results. [162] (10.1016/s0363-5023(87)80056-4)
[L4] Follow-up studies of up to 10 years after completion of treatment showed a good function of the reconstructed thumbs and fingers without trophic changes and with preserved sensibility on the whole surface. [163] (10.1016/0363-5023(89)90116-0)
[L1] There appears to be no benefit to tendon interposition or ligament reconstruction in the longer term. [164] (10.1016/j.jhsa.2011.11.027)
[L4] The long-term follow-up periods permit us to note a good morphologic integration and adaptation of the vascularized fibular graft in the forearm. [166] (10.1053/jhsu.1999.0604)
[L4] Long-term follow-up results show that patients with toe-to-hand transfers have acceptable adaptation to the reconstructed hand and good hand function. [167] (10.1016/j.jhsb.2005.09.017)
[L5] The long-term outcome should be monitored to determine the definitive role of the vascularized fibula for replacement of the proximal radius. [173] (10.1016/j.jse.2005.01.003)
[L4] The ulnar 2 digits play a significant role in overall grip strength of the entire hand. [185] (10.1197/j.jht.2006.07.009)
[L5] The article highlights advancements in surgical and therapy management for Dupuytren's disease, reviewing indications, surgical options, non-surgical techniques, and therapy interventions to assist in linking patient-specific problems to appropriate treatment choices. [192] (10.1016/j.jht.2013.10.006)
[L4] The fibula is considered more suitable than the rib for bridging forearm gaps due to its favorable biomechanic properties. [194] (10.1016/s0363-5023(81)80108-6)
[L4] However, magnetic resonance imaging indicates that the donor site is resurfaced with fibrous tissue. [206] (10.1177/0363546507306465)
[L4] Radiographs and three-phase bone scans showed union of the iliac bone block and the stump without any resorption in all three patients. [207] (10.1016/s0266-7681(02)00277-2)
[L5] X-ray showed neither recurrence of tumour nor resorption of the fibular graft. [208] (10.1016/0266-7681(89)90133-2)
[L4] The non-vascularised fibular graft was an effective solution for radius reconstruction in this series. [209] (10.1016/s1297-3203(01)00046-4)
[L4] [210] (10.1016/j.jhsa.2018.10.011)
[L5] Radiographs showed complete incorporation of the graft with normal bone healing and an appropriate joint space without signs of cartilage necrosis or degradation. [211] (10.1016/0363-5023(89)90185-8)
[L4] The study found that MRI identified the cartilaginous configuration precisely, which assisted in choosing the correct site to perform osteotomies and eliminated the need for secondary operations. [213] (10.1177/1753193420983213)
[Paper] The use of these grafts have allowed for rapid reliable healing of established scaphoid nonunions and MRI evidence of revascularization of Kienböck's disease. [214] (10.1097/00130911-199806000-00003)
[L5] Revascularization of the trapezium was achieved as shown by MRI 12 months after surgery. [217] (10.1016/j.jhsa.2004.06.009)
[L4] [218] (10.1016/0266-7681(92)90086-h)
[L5] The patients' lack of interest in having the thumb salvaged or reconstructed was almost unanimous. [219] (10.1016/s0363-5023(84)80086-6)
[L3] The study notes that while non-randomised, the technique appears better without an increased rate of rupture but with a shorter rehabilitation period. [223] (10.1177/1753193408091570)
[L4] A comparative analysis of the immediate and final radiographs of the graft showed an average 30% loss of bone mass despite integration. [225] (10.1016/s0266-7681(97)80411-1)
[L1] There is low level of evidence that both surgical and nonsurgical treatments provide clinically important improvements for recurrent Dupuytren contracture. [226] (10.1177/1558944721994220)
[L5] [229] (10.1016/j.hcl.2010.01.007)
[L5] [231] (10.1016/j.jhsa.2011.04.017)
[Textbook] Nonsurgical treatment options used for pathological scars and skin management techniques in surgical scar revision are also routinely applied in Dupuytren's disease. [233] (10.1007/978-3-642-22697-7_23)
[L4] Prolonged viability of the flap tissue has been verified by magnetic resonance imaging scanning and gadolinium perfusion studies. [235] (10.1016/s0363-5023(05)80137-6)
[L4] The reconstruction procedure provided a satisfactory functional result in a very active patient who refused any cosmetic prosthesis, demonstrating the usefulness of combining salvage microsurgical procedures with non-microsurgical methods. [236] (10.1054/jhsb.1999.0225)
[L5] Eight years after surgery, x-ray and clinical examination revealed no evidence of instability or material failure. [237] (10.1016/0363-5023(92)90132-9)
[L4] [238] (10.1016/j.injury.2008.06.007)
[L3] Despite the relatively high rate of non-union that necessitated additional operations, transplantation of allografts for the treatment of intercalary defects has a high rate of success and usually results in a functional limb. [239] (10.2106/00004623-199701000-00010)
[L4] If conservative measures have failed and operative treatment is undertaken, we recommend a programme of early post-operative mobilisation, together with static and dynamic splinting to minimise the loss of flexion. [240] (10.1016/0266-7681_90_90122-k)
[L4] [242] (10.1177/1753193408098904)
[L4] [248] (10.1142/s242483551672022x)
[L5] [251] (10.1177/1753193418793579)
[L4] There was no angular deformity of the grafts nor radiographic evidence of resorption or aseptic necrosis of the grafted bone at the time of the final evaluation. [252] (10.1097/bth.0b013e31816d92ad)
[L4] In less-experienced hands, omission of primary closure of donor site may prevent iatrogenic flap ischemia. [253] (10.1097/bth.0b013e31824e1fa2)
[L4] [255] (10.1016/s0266-7681(98)80123-x)
[L5] [258] (10.5435/00124635-201102000-00003)
[L5] [259] (10.1016/j.jhsa.2025.02.020)
[L4] [261] (10.1016/j.jhsg.2026.100957)
[L4] [262] (10.1177/1753193420956320)
[L4] The thumb can be restored nearly to original condition with acceptable donor site sequela. [263] (10.1016/j.jhsa.2013.08.047)
[L4] Approximately 13% of syndactyly reconstructions require reoperation, with most occurring within 4 years of the primary procedure. [264] (10.1016/j.jhsa.2024.08.012)
[L2] Early venous congestion is common, but can be managed non-operatively. [269] (10.1177/1753193417712879)
[L2] [270] (10.1177/1753193410397971)
[L4] No conclusive evidence exists in favor of an immediate versus a primary, early or delayed emergency reconstruction. [273] (10.1016/j.injury.2019.10.056)
[L4] Multidisciplinary management is essential to prevent retractive sequelae, and Z-plasties and Trident flaps remain the most effective and least traumatic options, especially in children. [275] (10.1016/j.hansur.2017.10.157)
[L4] [277] (10.1016/s0266-7681(96)80177-x)
[L4] The time elapsed between injury and surgery is not an important risk factor for a good outcome; rather, outcomes depend on proper surgical methods, the surgeon's experience, and early mobilization. [283] (10.1177/17531934211024435)
[L4] [284] (10.1177/1753193420939490)
[L4] We found the minimum duration between stage I surgery and stage II surgery to increase from 6 weeks early in our series to 3 months currently. [289] (10.1016/s0363-5023(88)80095-9)
[L5] [290] (10.1016/j.hcl.2020.03.011)
[L4] [291] (10.1177/1753193408101464)
[L4] The time required for healing of the great-toe defect was less than 1 month, and all patients were satisfied with the outcome. [292] (10.1016/s0363-5023(97)80090-1)
[L5] The selection of a free flap procedure in this case allowed a relatively short one-session procedure and a short period in hospital which is even more crucial in a patient with a short life-expectancy. [293] (10.1016/0266-7681(89)90013-2)
[L4] The duration of banking before thumb reconstruction should be no more than 2 weeks. [295] (10.1016/j.jhsa.2022.06.027)
[L5] Early microsurgical reconstruction following radical debridement significantly lowers postoperative morbidity, infection rate, and the number of subsequent procedures compared with delayed or late operations. [296] (10.1016/s0749-0712(02)00128-2)
[L4] We attribute this to better timing of the procedure and progressive experience gained by one surgeon using the same procedure. [297] (10.1016/s0363-5023(87)80057-6)

References¶

[1] Tendon Versus Nerve Transfers in Elbow, Wrist, and Hand Reconstruction. Hand Clinics. 2013. DOI: 10.1016/j.hcl.2013.04.010

[2] Firework-Related Injuries of the Hand. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2014.08.041

[3] Secondary Flexor Tendon Reconstruction, A Review. The Journal of Hand Surgery. 2007. DOI: 10.1016/j.jhsa.2007.08.018

[4] Posterior interosseous artery flap for severe hand injuries: Outcomes of reconstruction combined with local and regional flaps. Injury. 2026. DOI: 10.1016/j.injury.2026.113151

[5] Treatment of Boutonniere Finger Deformity in Rheumatoid Arthritis. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2011.05.029

[6] Flaps old and new. The Journal of Hand Surgery. 1981. DOI: 10.1016/s0363-5023(81)80002-0

[7] Treatment of the Triphalangeal Thumb. Techniques in Hand & Upper Extremity Surgery. 2004. DOI: 10.1097/00130911-200412000-00008

[8] 4.5 Year Follow-Up after Surgical Correction of Upper Extremity Deformities in Spastic Cerebral Palsy. Journal of Hand Surgery. 1999. DOI: 10.1054/jhsb.1999.0265

[11] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy, Evaluation, Clinical Examination, and Imaging > Evaluation and Clinical Examination: Current Concepts.

[12] Tachdjian S Pediatric Orthopaedics From The Texas Scottish Rite Hospital For Children E Book. Evaluation of the Child for Reconstruction.

[13] A comprehensive approach to surgical mangement of the type IIIA hypoplastic thumb. The Journal of Hand Surgery. 1998. DOI: 10.1016/s0363-5023(98)80081-6

[15] Soft Tissue Coverage of the Hand and Upper Extremity: The Reconstructive Elevator. The Journal of Hand Surgery. 2016. DOI: 10.1016/j.jhsa.2016.04.020

[16] Long-term patient-reported outcome measures of fingertip coverage with a homodigital unipedicle neurovascular island flap. Journal of Hand Surgery (European Volume). 2023. DOI: 10.1177/17531934231172081

[17] Microsurgical reconstruction of soft-tissue defects in digits. Injury. 2013. DOI: 10.1016/j.injury.2013.01.021

[18] Failed Extensor Tendon Repairs: Extensor Tenolysis and Reconstruction. Journal of the American Academy of Orthopaedic Surgeons. 2019. DOI: 10.5435/jaaos-d-18-00218

[19] Staged opposition transfer. The Journal of Hand Surgery. 1998. DOI: 10.1016/s0363-5023(98)80129-9

[20] Microsurgical thumb repair and reconstruction. Journal of Hand Surgery (European Volume). 2017. DOI: 10.1177/1753193417723310

[21] Free Muscle Flaps for Reconstruction of Upper Limb Defects. Hand Clinics. 2014. DOI: 10.1016/j.hcl.2014.01.001

[22] Measurement of Outcomes of Upper Limb Reconstructive Surgery for Tetraplegia. Archives of Physical Medicine and Rehabilitation. 2016. DOI: 10.1016/j.apmr.2015.10.110

[23] A Review and Meta-analysis of Adverse Events Related to Local Flap Reconstruction for Digital Soft Tissue Defects. Hand Clinics. 2020. DOI: 10.1016/j.hcl.2019.08.009

[24] Cross-finger flap for reconstruction of fingertip amputations: Long-term results. Orthopaedics & Traumatology: Surgery & Research. 2016. DOI: 10.1016/j.otsr.2016.03.006

[25] Long-Term Clinical and Radiological Outcomes of Radial Shortening Osteotomy and Vascularized Bone Graft in Kienböck Disease. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2012.11.016

[29] Microsurgical Flaps in Repair and Reconstruction of the Hand. Hand Clinics. 2017. DOI: 10.1016/j.hcl.2017.04.001

[30] Toe-to-thumb reconstruction. Injury. 2013. DOI: 10.1016/j.injury.2013.01.027

[31] Problems in managing reconstructive surgery for brachial plexus lesions contrasted with peripheral nerve lesions. The Journal of Hand Surgery: Journal of the British Society for Surgery of the Hand. 1986. DOI: 10.1016/0266-7681(86)90002-1

[32] Plastic and Reconstructive Surgery Management of Civilians and Military Injuries in the 2023-2024 Middle East Conflict. Injury. 2026. DOI: 10.1016/j.injury.2026.113720

[33] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 9Hand Surgery > Image DISORDERS OF THE MUSCULATURE OF THE HAND.

[34] Couverture d’une perte de substance palmaire par un lambeau synovial des fléchisseurs superficiels des doigts. Chirurgie de la Main. 2013. DOI: 10.1016/j.main.2013.09.001

[35] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Hand and Wrist Reconstruction: Microsurgery and Replantation > Summary.

[36] Exam Of The Hand Wrist 2Ed. 1.1 SKELETON OF THE HAND > The osseous skeleton.

[37] Utilisation du lambeau cerf-volant pour le traitement d’un sarcome épithélioïde du pouce. À propos d’un cas. Chirurgie de la Main. 2013. DOI: 10.1016/j.main.2013.08.003

[38] Reconstructive surgery of the post-burn boutonnière deformity. The Journal of Hand Surgery: Journal of the British Society for Surgery of the Hand. 1986. DOI: 10.1016/0266-7681(86)90006-9

[39] Optimizing Functional and Aesthetic Outcomes of Upper Limb Soft Tissue Reconstruction. Hand Clinics. 2014. DOI: 10.1016/j.hcl.2014.01.005

[41] The Krukenberg procedure revisited. Journal of Hand Surgery (European Volume). 2011. DOI: 10.1177/1753193411406479

[42] Interscapulothoracic resection of tumours of shoulder with a note on reconstruction. The Bone & Joint Journal. 2014. DOI: 10.1302/0301-620x.96b5.32241

[44] 40 years of experience in functional surgery of the tetraplegic upper limb. Hand Surgery and Rehabilitation. 2020. DOI: 10.1016/j.hansur.2020.05.012

[45] Severe complex injuries to the upper extremity: Revascularization and replantation. The Journal of Hand Surgery. 1991. DOI: 10.1016/0363-5023(91)90176-c

[46] Dupuytren Contracture Recurrence Following Treatment With Collagenase Clostridium Histolyticum (CORDLESS [Collagenase Option for Reduction of Dupuytren Long-Term Evaluation of Safety Study]): 5-Year Data. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2015.04.036

[47] Finger reconstruction using toe transplantation. The Journal of Hand Surgery: Journal of the British Society for Surgery of the Hand. 1986. DOI: 10.1016/0266-7681(86)90005-7

[48] Alternative Method for Thumb Reconstruction. Combination of 2 Techniques: Metacarpal Lengthening and Mini Wraparound Transfer. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2013.02.030

[49] Indications and Selection for Digital Amputation and Replantation. Journal of Hand Surgery. 2001. DOI: 10.1054/jhsb.2001.0595

[50] Use of a Reverse Metacarpal Bone Flap for the Treatment of Segmental Bone Defects of the Proximal Phalanges. The Journal of Hand Surgery. 2020. DOI: 10.1016/j.jhsa.2020.06.001

[51] Vascularised fibular grafts for reconstruction of extremity bone defects after resection of bone and soft-tissue tumours. The Bone & Joint Journal. 2017. DOI: 10.1302/0301-620x.99b9.bjj-2017-0219.r1

[52] The Glabrous Palmar Flap. Techniques in Hand & Upper Extremity Surgery. 2009. DOI: 10.1097/bth.0b013e3181ac9183

[53] Long-Term Outcomes Following Radial Polydactyly Reconstruction. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.05.006

[54] Outcome of arthrodesis for severe recurrent proximal interphalangeal joint contractures in Dupuytren’s disease. Journal of Hand Surgery (European Volume). 2020. DOI: 10.1177/1753193420960309

[55] Long-term patient reported outcomes and quality of life after syndactyly separation. Journal of Hand Surgery (European Volume). 2025. DOI: 10.1177/17531934251380997

[56] Current Reconstruction Options for Traumatic Thumb Loss. The Journal of Hand Surgery. 2016. DOI: 10.1016/j.jhsa.2016.09.012

[57] Arterial Conduits for Distal Upper Extremity Bypass. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2012.12.009

[58] Revision of residual deformities after primary surgery for Wassel-Flatt IV-D thumb duplication using a microsurgical free lateral great toe flap. Journal of Hand Surgery (European Volume). 2024. DOI: 10.1177/17531934231222400

[59] Costal cartilage graft for an unstable post-traumatic trapeziometacarpal intra-articular malunion in a pediatric patient: A case report. Hand Surgery and Rehabilitation. 2021. DOI: 10.1016/j.hansur.2020.10.014

[61] Le lambeau de fléchisseur superficiel des doigts dans le traitement des névromes en continuité du nerf médian. Chirurgie de la Main. 2009. DOI: 10.1016/j.main.2009.06.007

[62] Mirror hand-ulnar dimelia: a single centre experience with 13 patients. Journal of Hand Surgery (European Volume). 2022. DOI: 10.1177/17531934221116960

[63] Use of the parascapular flap in hand reconstruction. The Journal of Hand Surgery. 1986. DOI: 10.1016/s0363-5023(86)80241-6

[64] Reconstructive microsurgery in upper limb reconstruction: 30 years’ experience of a single surgeon. Journal of Hand Surgery (European Volume). 2020. DOI: 10.1177/1753193420915398

[65] Indications and Predictors for Reconstructive Surgery After Hand Burns. The Journal of Hand Surgery. 2017. DOI: 10.1016/j.jhsa.2017.02.006

[66] Current management of the mangled upper extremity. International Orthopaedics. 2012. DOI: 10.1007/s00264-012-1638-y

[69] Classification of failure of limb salvage after reconstructive surgery for bone tumours. The Bone & Joint Journal. 2014. DOI: 10.1302/0301-620x.96b11.34747

[72] Green S Operative Hand Surgery. Interosseous and Hypothenar Muscles.

[74] Hypoplasie du pouce : traitement en dehors des solutions microchirurgicales. Chirurgie de la Main. 2006. DOI: 10.1016/j.main.2006.01.001

[77] Exam Of The Hand Wrist 2Ed. Planning skin cover of the hand and forearm.

[80] Exam Of The Hand Wrist 2Ed. The arches of the hand > The metacarpal arch.

[82] A radial polydactyly classification system used for surgical planning. Journal of Hand Surgery (European Volume). 2021. DOI: 10.1177/1753193421995697

[84] Exam Of The Hand Wrist 2Ed. Techniques of investigation of the arterial supply by J P Melki > Vascularization of the thumb > Palmar aspect.

[91] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 9Hand Surgery > FLEXOR TENDON INJURY.

[92] Exam Of The Hand Wrist 2Ed. 1.3 MOVEMENTS OF THE HAND AND WRIST > Gliding mechanisms.

[93] Exam Of The Hand Wrist 2Ed. The dorsal skin.

[106] Classification and surgical treatment of the thumb-in-palm deformity in cerebral palsy and spastic paralysis. The Journal of Hand Surgery. 1995. DOI: 10.1016/s0363-5023(05)80101-7

[108] Harnessing the uninjured hemisphere for treatment of the stroke or brain-injured patient – evolution of the contralateral C7 transfer. Journal of Hand Surgery (European Volume). 2025. DOI: 10.1177/17531934251314640

[110] Ulnar artery distal cutaneous descending branch as free flap in hand reconstruction. Injury. 2009. DOI: 10.1016/j.injury.2009.04.009

[112] Amputations of the Fingers and Hand: Indications for Replantation. Journal of the American Academy of Orthopaedic Surgeons. 1998. DOI: 10.5435/00124635-199803000-00004

[113] Green S Operative Hand Surgery. EVOLUTION IN THE TREATMENT OF MANGLING INJURIES > CONCLUSION.

[116] Digital Syndactyly Release. Techniques in Hand & Upper Extremity Surgery. 2010. DOI: 10.1097/bth.0b013e3181cf7d70

[117] Salvage of Complete Degloved Digits With Reversed Vascularized Pedicled Forearm Flap: A New Technique. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2012.01.032

[118] One-stage prosthetic dermal repair of skin defects in the donor area of the great toe nails flap. Injury. 2025. DOI: 10.1016/j.injury.2025.112450

[120] Intérêt des lambeaux locaux dans la prise en charge des brûlures profondes des doigts : à propos de 62 cas. Hand Surgery and Rehabilitation. 2019. DOI: 10.1016/j.hansur.2019.10.070

[121] Primary Reconstruction of a Degloved Middle Finger with a Temporoparietal Free Flap. Journal of Hand Surgery. 1999. DOI: 10.1054/jhsb.1999.0199

[122] Reverse Flow Shunt Restricted Arterialized Venous Free Flap. The Journal of Hand Surgery. 2018. DOI: 10.1016/j.jhsa.2018.02.023

[123] Parallelogram flap versus homodigital island flap in the treatment of fingertip defects with bone exposure: a prospective controlled study. Journal of Orthopaedic Surgery and Research. 2022. DOI: 10.1186/s13018-022-03214-1

[125] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Pediatric Upper Extremity Disorders > Summary.

[126] Metacarpophalangeal Joint Extensor Tendon Subluxation: A Reconstructive Stabilization Technique. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2012.12.021

[127] Chapter 33 Hand and Wrist Reconstruction: Microsurgery and Replantation. 2020.

[128] Dupuytren S Disease And Related Hyperproliferative Disorders. 54. The Future of Dupuytren’s Research and Treatment > 54.4 Mechanical Measurements and Procedures > 54.4.4 Imaging.

[129] Long-Term Follow-Up of Basal Joint Resection Arthroplasty of the Thumb With Transfer of the Abductor Pollicis Brevis Origin to the Flexor Carpi Radialis Tendon. The Journal of Hand Surgery. 2009. DOI: 10.1016/j.jhsa.2009.03.016

[130] Green S Operative Hand Surgery. EVOLUTION IN THE TREATMENT OF MANGLING INJURIES > PRINCIPLES.

[131] Proximal Interphalangeal Joint Prosthetic Arthroplasty. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2010.04.005

[132] Two-stage reconstruction of apert acrosyndactyly. The Journal of Hand Surgery. 1997. DOI: 10.1016/s0363-5023(97)80170-0

[133] Comparison of hamate versus second or third toe osteochondral graft using magnetic resonance imaging for reconstruction of proximal interphalangeal fracture-dislocations. Journal of Hand Surgery (European Volume). 2023. DOI: 10.1177/17531934231220783

[134] Refinements and Secondary Surgery After Flap Reconstruction of the Traumatized Hand. Hand Clinics. 2014. DOI: 10.1016/j.hcl.2014.01.004

[135] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 9Hand Surgery > 1. Replantation.

[136] Rockwood And Green S Fractures In Adults. Effect of Blast on the Musculoskeletal System > Summary.

[137] Dorso-Ulnar Osteocutaneous Reverse Flow Flap of the Thumb. Journal of Hand Surgery. 2001. DOI: 10.1054/jhsb.2001.0584

[138] Use of an Iliac Crest Growth Plate for the Development of a Neo-articulation for Congenital Transverse Deficiencies at the Wrist. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2012.06.023

[139] Orthopaedic Knowledge Update Trauma. Amputations in Patients With Trauma > Introduction.

[141] A Classification System of Radial Polydactyly: Inclusion of Triphalangeal Thumb and Triplication. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2007.12.012

[142] Distraction-fixation in the primary treatment of metacarpal bone loss. The Journal of Hand Surgery. 1981. DOI: 10.1016/s0363-5023(81)80164-5

[143] Toe-to-finger free flexor tendon transfer for digital flexion reconstruction. The Journal of Hand Surgery. 2003. DOI: 10.1016/s0363-5023(03)80402-1

[146] Hand Transplantation: Evolution of a Personal Outlook. The Journal of Hand Surgery. 2017. DOI: 10.1016/j.jhsa.2017.01.019

[147] Round table discussion. The management of complete brachial plexus birth injury. Journal of Hand Surgery (European Volume). 2025. DOI: 10.1177/17531934251397218

[148] The versatile thoracodorsal artery perforator flap for extremity reconstruction: from simple to five types of advanced applications and clinical outcomes. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-04480-3

[150] Les transferts articulaires vascularisés à partir du pied. Chirurgie de la Main. 2010. DOI: 10.1016/j.main.2010.10.015

[152] Reconstruction of a hand, amputated at the metacarpophalangeal level, by means of combined second and third toes from each foot: A case report. The Journal of Hand Surgery. 1986. DOI: 10.1016/s0363-5023(86)80139-3

[157] Interposition Vein Graft Configurations for Microsurgical Revascularization of the Ischemic Hand. Techniques in Hand & Upper Extremity Surgery. 1999. DOI: 10.1097/00130911-199906000-00009

[159] Reconstruction of the Adult and Pediatric Burned Hand. Hand Clinics. 2017. DOI: 10.1016/j.hcl.2016.12.006

[162] Reconstruction of a digitless hand. The Journal of Hand Surgery. 1987. DOI: 10.1016/s0363-5023(87)80056-4

[163] The bone-lengthening method in hand reconstruction: Twenty years' experience. The Journal of Hand Surgery. 1989. DOI: 10.1016/0363-5023(89)90116-0

[164] Five- to 18-Year Follow-Up for Treatment of Trapeziometacarpal Osteoarthritis: A Prospective Comparison of Excision, Tendon Interposition, and Ligament Reconstruction and Tendon Interposition. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2011.11.027

[165] Green S Operative Hand Surgery. EVALUATION.

[166] Congenital pseudarthrosis of both forearm bones: Long-term results of two cases managed by free vascularized fibular graft. The Journal of Hand Surgery. 1999. DOI: 10.1053/jhsu.1999.0604

[167] Toe-to-Hand Transfers: More Than 20 Years Follow-Up of Five Post-Traumatic Cases. Journal of Hand Surgery. 2006. DOI: 10.1016/j.jhsb.2005.09.017

[171] Miller S Review Of Orthopaedics. SECTION 16 PATELLAR TRACKING IN TOTAL KNEE ARTHROPLASTY > MUSCULOSKELETAL TUMORS.

[173] Reconstruction of the proximal half of the radius using vascularized fibula: Significance of soft-tissue reconstruction. Journal of Shoulder and Elbow Surgery. 2006. DOI: 10.1016/j.jse.2005.01.003

[174] Apley And Solomon S Concise System Of Orthopaedics And Trauma. PRINCIPLES OF TREATMENT.

[185] Contribution of the Ulnar Digits to Overall Grip Strength. Journal of Hand Therapy. 2006. DOI: 10.1197/j.jht.2006.07.009

[192] Surgical and therapy update on the management of Dupuytren's disease. Journal of Hand Therapy. 2014. DOI: 10.1016/j.jht.2013.10.006

[194] Congenital pseudarthrosis of the forearm—Two cases treated by free vascularized fibular graft. The Journal of Hand Surgery. 1981. DOI: 10.1016/s0363-5023(81)80108-6

[206] Donor Site Evaluation after Autologous Osteochondral Mosaicplasty for Cartilaginous Lesions of the Elbow Joint. The American Journal of Sports Medicine. 2007. DOI: 10.1177/0363546507306465

[207] Composite Osteocutaneous Groin Flap Combined with Neurovascular Island Flap for Thumb Reconstruction. Journal of Hand Surgery. 2003. DOI: 10.1016/s0266-7681(02)00277-2

[208] En bloc excision and reconstruction with a fibular autograft of giant-cell tumour of the metacarpal—A case report. The Journal of Hand Surgery: Journal of the British Society for Surgery of the Hand. 1989. DOI: 10.1016/0266-7681(89)90133-2

[209] Reconstruction du radius par greffon fibulaire non vascularisé pour tumeur osseuse primitive (à propos de quatre cas). Chirurgie de la Main. 2001. DOI: 10.1016/s1297-3203(01)00046-4

[210] Pollicization of the Index Finger in the United States: Early Readmission and Complications. The Journal of Hand Surgery. 2019. DOI: 10.1016/j.jhsa.2018.10.011

[211] Repair of the proximal interphalangeal joint with a homograft. The Journal of Hand Surgery. 1989. DOI: 10.1016/0363-5023(89)90185-8

[213] MRI analysis and surgical treatment of Wassel Type IV duplicated thumbs. Journal of Hand Surgery (European Volume). 2021. DOI: 10.1177/1753193420983213

[214] Vascularized Pedicled Bone Grafts for Disorders of the Carpus. Techniques in Hand & Upper Extremity Surgery. 1998. DOI: 10.1097/00130911-199806000-00003

[217] Osteonecrosis of the trapezium treated with a vascularized distal radius bone graft. The Journal of Hand Surgery. 2004. DOI: 10.1016/j.jhsa.2004.06.009

[218] Complications and Morbidity of the Donor and Recipient Sites in 123 Lateral Arm Flaps. Journal of Hand Surgery. 1992. DOI: 10.1016/0266-7681(92)90086-h

[219] Rodeo roping thumb injuries. The Journal of Hand Surgery. 1984. DOI: 10.1016/s0363-5023(84)80086-6

[223] Clinical Results of Flexor Tendon Repair in Zone II Using a Six-Strand Double-Loop Technique Compared with a Two-Strand Technique. Journal of Hand Surgery (European Volume). 2008. DOI: 10.1177/1753193408091570

[225] Use of a Bone Block Graft from the Iliac Crest with Rigid Fixation to Correct Diaphyseal Defects of the Radius and Ulna. Journal of Hand Surgery. 1997. DOI: 10.1016/s0266-7681(97)80411-1

[226] Outcomes of Management of Recurrent Dupuytren Contracture: A Systematic Review and Meta-analysis. HAND. 2021. DOI: 10.1177/1558944721994220

[229] Microsurgical Complications in the Upper Extremity. Hand Clinics. 2010. DOI: 10.1016/j.hcl.2010.01.007

[231] Reconstructive Treatment of Soft Tissue Sarcoma of the Upper Extremity. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2011.04.017

[233] 23. Plastic Surgical Management of Scars and Soft Tissue Contractures. Dupuytren’s Disease and Related Hyperproliferative Disorders. 2012. DOI: 10.1007/978-3-642-22697-7_23

[234] 6. Adult Reconstructive Surgery. 2013.

[235] The retrograde radial fascial forearm flap: Surgical rationale, technique, and clinical application. The Journal of Hand Surgery. 1995. DOI: 10.1016/s0363-5023(05)80137-6

[236] Pinch Reconstruction by Hand o Hand Finger Transfer Associated with Hallux Transfer after a Severe Frostbite Injury. Journal of Hand Surgery. 1999. DOI: 10.1054/jhsb.1999.0225

[237] Segmental metacarpal replacement with bone cement and a silicone joint prosthesis: A case report. The Journal of Hand Surgery. 1992. DOI: 10.1016/0363-5023(92)90132-9

[238] Versatility of the island forearm flap in the management of extensive skin defects of the hand. Injury. 2008. DOI: 10.1016/j.injury.2008.06.007

[239] The Results of Transplantation of Intercalary Allografts after Resection of Tumors. A Long-Term Follow-up Study. The Journal of Bone and Joint Surgery-American Volume*. 1997. DOI: 10.2106/00004623-199701000-00010

[240] Management of Simple Camptodactyly. Journal of Hand Surgery. 1990. DOI: 10.1016/0266-7681_90_90122-k

[242] The Gigogne Flap: An Original Technique for an Optimal Pulp Reconstruction. Journal of Hand Surgery (European Volume). 2009. DOI: 10.1177/1753193408098904

[248] Does Graft on Flap Method Work on Sequela of Fingertip Amputation?. The Journal of Hand Surgery (Asian-Pacific Volume). 2016. DOI: 10.1142/s242483551672022x

[251] Surgical techniques for reconstruction of the hypoplastic thumb. Journal of Hand Surgery (European Volume). 2018. DOI: 10.1177/1753193418793579

[252] Finger Joint Reconstruction with Costal Osteochondral Graft. Techniques in Hand & Upper Extremity Surgery. 2008. DOI: 10.1097/bth.0b013e31816d92ad

[253] Safe and Easy Method to Preserve Fingertip Contour in VY-Plasty. Techniques in Hand & Upper Extremity Surgery. 2012. DOI: 10.1097/bth.0b013e31824e1fa2

[254] Free_Vascularized_Fibular_Graft_Reconstruction_of_Large_00003086-201002000-00042. 2010.

[255] Ring Avulsion Injuries Managed with Homodigital and Heterodigital Venous Island Conduit (VIC) Flaps. Journal of Hand Surgery. 1998. DOI: 10.1016/s0266-7681(98)80123-x

[258] Reconstruction of Soft-tissue Injury Associated With Lower Extremity Fracture. American Academy of Orthopaedic Surgeon. 2011. DOI: 10.5435/00124635-201102000-00003

[259] The Acute Burned Upper Extremity: Evolution of Practices and Management. The Journal of Hand Surgery. 2025. DOI: 10.1016/j.jhsa.2025.02.020

[261] Reconstruction of the Extensor Carpi Ulnaris Subsheath Using a Fascia Lata Allograft. Journal of Hand Surgery Global Online. 2026. DOI: 10.1016/j.jhsg.2026.100957

[262] Fingertip defect reconstruction with a modified pivot flap. Journal of Hand Surgery (European Volume). 2020. DOI: 10.1177/1753193420956320

[263] Onycho-Osteocutaneous Defects of the Thumb Reconstructed by Partial Toe to Hand. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2013.08.047

[264] Revision Surgery Following Primary Reconstruction for Hand Syndactyly. The Journal of Hand Surgery. 2024. DOI: 10.1016/j.jhsa.2024.08.012

[269] Venous flaps for coverage of traumatic soft tissue defects of the hand: a systematic review. Journal of Hand Surgery (European Volume). 2017. DOI: 10.1177/1753193417712879

[270] The efficacy and safety of fasciectomy and fasciotomy for Dupuytren’s contracture in European patients: a structured review of published studies. Journal of Hand Surgery (European Volume). 2011. DOI: 10.1177/1753193410397971

[273] Emergency toe-to-hand transfer for post-traumatic finger reconstruction: A multicenter case series. Injury. 2019. DOI: 10.1016/j.injury.2019.10.056

[275] Les sequelles de brûlures palmodigitales. Hand Surgery and Rehabilitation. 2017. DOI: 10.1016/j.hansur.2017.10.157

[277] Toe To Hand Transfer in Children. Journal of Hand Surgery. 1996. DOI: 10.1016/s0266-7681(96)80177-x

[283] Up to five-week delay in primary repair of Zone 2 flexor tendon injuries: outcomes and complications. Journal of Hand Surgery (European Volume). 2021. DOI: 10.1177/17531934211024435

[284] Modified Viegas dorsal capsuloplasty for chronic partial injury of the scapholunate ligament in young athletes: outcomes at 24 months. Journal of Hand Surgery (European Volume). 2020. DOI: 10.1177/1753193420939490

[289] Staged flexor tendon reconstruction in the fingers and hand. The Journal of Hand Surgery. 1988. DOI: 10.1016/s0363-5023(88)80095-9

[290] Soft Tissue Coverage for Severe Infections. Hand Clinics. 2020. DOI: 10.1016/j.hcl.2020.03.011

[291] Free ‘Mini’ Groin Flap for Digital Resurfacing. Journal of Hand Surgery (European Volume). 2009. DOI: 10.1177/1753193408101464

[292] Resurfacing of the donor defect after wrap-around toe transfer with a free lateral forearm flap. The Journal of Hand Surgery. 1997. DOI: 10.1016/s0363-5023(97)80090-1

[293] Pain Relief after Free Flap Reconstruction in Adriamycin Necrosis on the Dorsum of the Hand. A Case Report. Journal of Hand Surgery. 1989. DOI: 10.1016/0266-7681(89)90013-2

[295] Secondary Thumb Reconstruction via Ectopic Banking of Bony Phalanges From a Nonreplantable Amputated Thumb: A Follow-Up Study. The Journal of Hand Surgery. 2024. DOI: 10.1016/j.jhsa.2022.06.027

[296] Soft tissue coverage in devastating hand injuries. Hand Clinics. 2003. DOI: 10.1016/s0749-0712(02)00128-2

[297] Evaluation of a uniform operative technique to treat syndactyly. The Journal of Hand Surgery. 1987. DOI: 10.1016/s0363-5023(87)80057-6

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