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Reconstructive Surgery

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

Overview

Secondary flexor tendon reconstruction encompasses delayed treatment and both one-stage and two-stage techniques [1]. The "reconstructive elevator" concept permits surgeons to select complex reconstructions for specialized function and aesthetics rather than adhering strictly to the simplest technique [6]. In the setting of type II pelvic resections, composite reconstruction using irradiated autograft plus total hip replacement is feasible but fraught with complications, necessitating careful consideration of high reoperation risks when selecting alternatives [10]. For chronic finger metacarpophalangeal joint collateral ligament rupture, repair augmented by an A2 pulley flap is simple and graft-free but has limited indications [17].

Thumb reconstruction offers diverse microsurgical transfer options, providing great freedom of choice yet considerably restricting options if all functional and cosmetic requirements must be met [21]. The combination of metacarpal lengthening and mini wraparound transfer is primarily chosen by selected patients refusing standard microsurgical reconstruction due to the longer treatment period [19]. For segmental bone defects of the proximal phalanges, a reverse metacarpal bone flap is recommended only as a salvage procedure [22]. Congenital transverse wrist deficiencies may be addressed with an iliac crest growth plate to create a neo-articulation, yielding good functional outcomes and potentially reducing the need for prosthesis acceptance [49].

Vascularized composite allotransplantation (VCA) is expected to become a major milestone through enhancements in immune modulation, surgical indication, patient selection, and posttransplant care [51]. Heterotopic nerve transfer donor selection requires careful weighing against alternatives, specifically considering the risk of donor nerve impairment and the potential narrowing of future reconstructive options [62]. The fascia-only reverse posterior interosseous artery flap offers major advantages including confinement of the donor site to the ipsilateral extremity, no requirement for microsurgery, and improved cosmesis via primary closure without a skin graft [63].

Anatomy & Pathophysiology

Optimal outcomes in acute surgical management of hand burns require meticulous surgical technique combined with preoperative and postoperative hand therapy to preserve function and prevent contracture [14]. Accurate diagnosis and management of hand and carpal fractures and dislocations are predicated on a thorough physical examination and appropriate imaging to limit joint stiffness while preserving mobility and function [65]. In soft tissue repair of the hand and digital reconstruction, sensation constitutes 40% of the goal, while length and appearance account for 50% [79].

Osseous Reconstruction: Nonvascularized autogenous bone graft is capable of restoring good hand function in severe injuries with substantial phalangeal bone loss [75]. Toe-to-hand transfers for posttraumatic reconstruction of the hand display improved strength of thumb reconstructions and reduced need for secondary surgery [72].

Neural and Tendon Dynamics: Routing of the extensor pollicis longus (EPL) tendon through the first dorsal compartment allows reproduction of the action of thumb extension and abduction and restores thumb clearance from the palm [70]. Transfer of the flexor carpi radialis to the abductor pollicis brevis tendon for restoration of tip-pinch in severe carpal tunnel syndrome demonstrates good functional outcomes, especially in the ability to oppose the thumb across the palm, patient satisfaction, and no complications [81]. Extension strengths of the thumb and index finger of the operated hand are approximately 20% lower compared to the contralateral hand following extensor indicis proprius tendon transfer for extensor pollicis longus tendon rupture, yet clinical functional scores and range of motion are favourable [76]. In radial nerve palsy treated with a flexor carpi ulnaris set of triple tendon transfer, range of wrist motion and strength of the wrist and fingers are less than normal, yet hand function remains good [56]. Room still remains for improved thumb motion with both nerve and tendon transfer procedures for radial nerve paralysis reconstruction [82]. Fundamental muscle-tendon-joint mechanics studies allow for single-stage surgical reconstruction of hand function and early postoperative activity-based training in patients with cervical spinal cord injuries [71].

Kinematics and Deformity Correction: Both intrinsic balancing techniques improved grasp, but only the House procedure restored hand kinematics approximating those of an intrinsic-activated hand [43]. Surgical reconstruction for thumb deformity in cerebral palsy aims to create a stable thumb capable of satisfactory grasp and release by decreasing deformity, balancing muscle forces, and stabilising joints [73]. A rationale for a dynamic stabilization approach is presented based on the unique anatomy of the thumb [59]. Correction of wrist deformity using extensor carpi ulnaris-tenodesis enables more ergonomic hand use and may help prevent shoulder pain [83]. Variation in methods of outcome measurement of thumb function suggests that consistency and efficacy of current methods are less than ideal, and it may be appropriate to consider applying a standard global assessment of thumb function to all congenital conditions affecting the thumb [85].

Prosthetics and Congenital Anomalies: The use of a proximity sensor in a novel prosthesis for upper extremity phocomelia eliminates the need for forceful movements of the residual finger to use mechanical switches or levers [61]. Mechanical solutions to minimize force required at the wrist to activate grip are still required for 3D-printed custom-designed prostheses for partial hand amputation [64]. 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 [77]. Clinical, bench, and biomechanical research is needed to test theories and ascertain the most effective intervention science for the painful thumb [42].

Classification

Secondary Flexor Tendon Reconstruction: Indications and methods encompass delayed treatment alongside both 1-stage and 2-stage reconstruction protocols [1].

Radial Polydactyly: A proposed classification system supplements Wassel's classification by providing clear guidance on surgical methods and required surgeon expertise levels [31]. A modified classification system, including triphalangeal thumb and triplication, serves as a practical and utilitarian scheme for nomenclature that may assist comparison of treatment outcomes and individual cases [50].

Ring Avulsion Injuries: The current classification of ring avulsion injuries requires modification to clarify the differences between total avulsion of the soft tissue alone and avulsion with amputation [41].

Brachial Plexus Birth Injury: There is a recognized need for more detailed classification systems and agreed outcome measures to facilitate comparison of outcomes in the management of complete brachial plexus birth injury [53].

Other Considerations: Reconstructive Philosophy: 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 [6]. Amputation is a reconstructive procedure designed to help the patient create a new interface with the world and resume their life, and it should never be viewed as a failure [26].

Anatomical Characterization: High-resolution MRI is a reliable method of characterizing the anatomy of hamate versus second or third toe osteochondral grafts and could be a useful clinical tool in determining reconstructive options for proximal interphalangeal fracture-dislocations [20].

Outcome Measurement Disparity: There is wide disparity in scoring systems, definition of recurrence, and recording of complications in surgical treatments for primary Dupuytren's disease, making critical comparison of techniques impossible [67].

Clinical Presentation

The clinical evaluation of reconstructive candidates requires distinguishing between acute trauma, chronic arthropathy, and congenital or neurogenic etiologies. In acute closed traumatic injury to the supraclavicular brachial plexus, early surgery is indicated within the first 2 weeks if the patient is fit, the injury pattern is clear, and a reconstruction plan is established [3]. If these criteria are not met, surgery is better delayed until 2 to 3 months to refine the surgical plan [3]. Conversely, severe isolated lower brachial plexus (Klumpke) palsy presentations may be missed if not recognized, resulting in lost opportunities for reconstruction [12]. For obstetric brachial plexus palsy beyond primary nerve repair, clinical assessment must focus on understanding and correcting pathophysiology and deformation, though measurement of outcomes remains challenging [32].

In the context of hand trauma and reconstruction, microsurgical techniques for severe injury, including replantation and reconstruction, have demonstrated significant improvements in early sensory function and daily activity capacity [36]. For fingertip coverage, the homodigital unipedicle neurovascular island flap is a safe and reliable option yielding satisfactory long-term patient-reported and objective outcomes [4]. In pediatric replantation, clinicians must account for specific differences in anatomy, physiology, mechanism of injury, surgical technique, and outcomes [35]. Children with obstetrical brachial plexus palsy who undergo microsurgical reconstruction commonly report pain [37]. For acute hand burns, optimal outcomes require meticulous surgical technique combined with preoperative and postoperative hand therapy [14].

Chronic deformities and arthropathies present distinct diagnostic challenges. Thumb deformities in rheumatoid arthritis are common and significantly compromise function; treatment is directed by the specific deformity type and joint involvement [34]. Nonsurgical management is indicated for early stages, whereas surgical reconstruction or salvage is indicated for advanced disease [34]. Long-term results following soft tissue reconstruction for Boutonniere finger deformity in rheumatoid arthritis are unreliable, making recurrent or persistent deformities best treated with a salvage procedure [2]. Secondary flexor tendon reconstruction indications and methods, including delayed treatment and 1-stage and 2-stage reconstruction, are reviewed [1].

Reconstructive surgery for upper extremity deformities in spastic cerebral palsy produces significant functional improvements at 6 months, which remain essentially unchanged at the 4.5-year follow-up [5]. Appropriate interventions and management of expectations optimize limb appearance and function in the spastic upper extremity in children while avoiding unexpected sequelae [29]. Hand surgery principles emphasize the balance between restoring function and maintaining aesthetic appearance [30]. For the hypoplastic thumb, preoperative assessment and intraoperative findings of all thumb elements should be considered in surgical decision-making [15]. In cases of fifth metacarpal resection, Y-shaped bone fusion to the fourth metacarpal showed no signs of inferior bone quality or fracture risk despite non-anatomical reconstruction, with the patient regaining almost complete function [8].

When considering complex or salvage scenarios, 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 [6]. A thorough understanding of complex anatomy and a working knowledge of reconstructive options are essential for successful outcomes in failed extensor tendon repairs [7]. In isolated middle finger reconstruction, distraction lengthening following vascularized second toe transfer can achieve improved aesthetic and functional outcomes in appropriate patients [33]. 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 [13].

Investigations

Plain radiography: Further radiographs prior to surgical treatment are unnecessary for resection of a giant cell tumour of the proximal phalanx and reconstruction by iliac crest graft [66]. Soft tissue releases offer advantages over bony procedures like arthrodesis and arthroplasty in patients with scleroderma joint contractures, particularly in patients with normal joint radiographs [93]. Bone resorption occurred in the digit reconstructed using the circumferential method for pulley reconstruction seven months after surgery, though the true incidence remains unclear as radiographs are not commonly performed after such procedures [94].

MRI: High-resolution MRI is a reliable method of characterizing the anatomy of structures used in reconstruction of proximal interphalangeal fracture-dislocations and could be a useful clinical tool in determining reconstructive options [20]. 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 [84]. Magnetic resonance imaging indicates that the donor site after autologous osteochondral mosaicplasty for cartilaginous lesions of the elbow joint is resurfaced with fibrous tissue [78].

Other Considerations: A majority of experts (83%) believe standardized long-term clinical follow-up is necessary for patients with brachial plexus birth palsy, but no consensus exists on specific time points or the necessity of standardized radiological follow-up [96].

Treatment

Non-Operative

Treatment options for hallux rigidus and osteoarthrosis of the first metatarsophalangeal joint range from non-operative measures to various surgical procedures, with selection depending on disease stage and patient factors [80]. Surgical and therapy management for Dupuytren's disease includes reviewing indications, surgical options, non-surgical techniques, and therapy interventions to assist in linking patient-specific problems to appropriate treatment choices [74]. There is a low level of evidence that both surgical and nonsurgical treatments provide clinically important improvements for recurrent Dupuytren contracture [88]. Nonsurgical treatment options used for pathological scars and skin management techniques in surgical scar revision are routinely applied in Dupuytren's disease [90]. Moderate nonprogressive coxa vara in childhood often does not require surgery [86].

Operative

Indications: Surgical management for coxa vara in childhood is indicated for progressive, painful, unilateral deformity or leg-length discrepancy [86]. Secondary flexor tendon reconstruction includes delayed treatment and 1-stage and 2-stage reconstruction methods [1]. 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 [2]. Reconstructive surgery for upper extremity deformities in spastic cerebral palsy produced significant functional improvements at 6 months which remained essentially unchanged at 4.5-year follow-up [5]. Surgical management for Dupuytren's disease includes reviewing indications, surgical options, non-surgical techniques, and therapy interventions to assist in linking patient-specific problems to appropriate treatment choices [74]. Treatment options for hallux rigidus and osteoarthrosis of the first metatarsophalangeal joint range from non-operative measures to various surgical procedures including cheilectomy, arthroplasty, and arthrodesis [80].

Surgical Approach / Technique: Homodigital unipedicle neurovascular island flaps provide satisfactory long-term patient-reported outcome measures and objective outcomes and are considered safe and reliable for fingertip coverage [4]. Reconstruction using parallelogram flaps for fingertip defects with bone exposure is easier and more versatile than homodigital island flaps, with better functions, less morbidity, and better aesthetics [18]. A 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 [9]. A reversed vascularized pedicled forearm flap provides adequate soft tissue and good functional outcome for salvage of complete degloved digits compared with other salvage procedures [40]. Collateral ligament repair augmented by an A2 pulley flap for chronic ligament rupture of the finger metacarpophalangeal joint does not require harvesting of a graft and is simple, though it has limited indications [17]. A reconstructive stabilization technique for metacarpophalangeal joint extensor tendon subluxation offers a simple, effective, and strong repair with minimal donor site morbidity and a good prognosis for recovery [44]. The method of soft-tissue reconstruction after interscapulothoracic resection of shoulder tumors has no effect on functional outcome [16].

Implant Selection: Composite reconstruction with irradiated autograft plus total hip replacement after type II pelvic resections for tumors is feasible but fraught with complications [10]. The high risk of complications and reoperations associated with composite reconstruction using irradiated autograft plus total hip replacement should be considered when selecting alternative reconstruction methods [10]. Transplantation of allografts for the treatment of intercalary defects has a high rate of success and usually results in a functional limb despite a relatively high rate of non-union that necessitated additional operations [92]. Y-shaped bone fusion to the fourth metacarpal after en-bloc resection of the fifth metacarpal resulted in no signs of inferior bone quality or risk of fracture and allowed the patient to regain almost complete function [8].

Alignment / Balancing Strategy: No substantial clinical or radiological difference was recognized between radial shortening osteotomy and vascularized bone graft in long-term outcomes for Kienböck disease [11]. Different microsurgical transfer techniques for thumb repair suggest great freedom of surgical choices, but choices are considerably restricted if all functional and cosmetic requirements are to be met [21]. The combination of metacarpal lengthening and mini wraparound transfer for thumb reconstruction is mainly chosen by selected patients who refuse standard microsurgical thumb reconstruction because it requires a longer treatment period [19]. Pinch reconstruction by hand-to-hand finger transfer associated with hallux transfer after severe frostbite injury provided a satisfactory functional result in a very active patient who refused any cosmetic prosthesis [91].

Pain Management: Non-medical people do not consider the unattractive appearance of the Krukenberg procedure to outweigh its functional outcome [13].

Adjuncts: A six-strand double-loop technique for flexor tendon repair in zone II appears better than a two-strand technique without an increased rate of rupture but with a shorter rehabilitation period [87].

Setting of Care: Microsurgery has made replantation a routine procedure with reliable viability rates, though achieving a satisfactory functional result after finger and hand replantation is difficult and depends on a variety of factors [39]. Successful reconstruction of the mangled upper extremity is largely based upon the outcomes of the initial surgical treatment that is dependent on the adequacy of débridement [45].

Revision: The use of a reverse metacarpal bone flap for segmental bone defects of the proximal phalanges is recommended only as a salvage procedure [22]. Contralateral C7 transfer for stroke or brain-injured patients has demonstrated significant improvements in upper limb function, confirming the procedure's safety and efficacy, with donor site morbidity typically being mild and transient [38].

Complications

Other Considerations: 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 [2]. Early surgery for closed traumatic injury to the supraclavicular brachial plexus can be performed within the first 2 weeks if the patient is fit, the injury pattern is clear, and a reconstruction plan is established; otherwise, it is better to wait until 2 to 3 months to refine the surgical plan [3]. Composite reconstruction with irradiated autograft plus total hip replacement after Type II pelvic resections for tumors is fraught with complications and carries a high risk of reoperations [10]. Revision rates for radial polydactyly reconstruction trended upward over time despite maintenance of favorable scores on objective outcome measures [23]. Approximately 13% of syndactyly reconstructions require reoperation, with most occurring within 4 years of the primary procedure [97]. Proximal interphalangeal joint prosthetic arthroplasty requires further long-term follow-up and prospective randomized comparisons to better define rates of revision, failure, and complications [47]. Vascularised fibular grafts for reconstruction of extremity bone defects after resection of bone and soft-tissue tumours are associated with a relatively high rate of complications [52]. 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 [25].

Recovery

Light activity (weeks): For closed traumatic injury to the supraclavicular brachial plexus, early surgery can be performed within the first 2 weeks if the patient is fit, the injury pattern is clear, and a reconstruction plan is established [3]. In cases where conditions for early surgery are not met, surgery is better delayed until 2 to 3 months to refine the surgical plan [3].

Full activity (months): Patients treated with modified Viegas dorsal capsuloplasty for chronic partial injury of the scapholunate ligament in young athletes could return to their original competitive activity within 6 months after surgery [103]. Reconstructive surgery for upper extremity deformities in spastic cerebral palsy produced significant functional improvements at 6 months [5]. Arthrodesis for severe recurrent proximal interphalangeal joint contractures in Dupuytren's disease allows for a fairly rapid return to function [55].

Complete recovery / outcome plateau (months): Functional improvements from reconstructive surgery for upper extremity deformities in spastic cerebral palsy remained essentially unchanged at the 4.5-year follow-up [5]. Long-term results after surgical reconstruction for radial polydactyly were excellent [23]. Long-term patient-reported outcome measures and objective outcomes for fingertip coverage with a homodigital unipedicle neurovascular island flap are satisfactory [4]. Long-term functional follow-up of patients treated with a free groin flap to reconstruct a dorsal hand skin defect in replantation of multi-finger amputations is not available [57].

Rehabilitation protocol: Outcomes for primary repair of Zone 2 flexor tendon injuries depend on proper surgical methods, the surgeon's experience, and early mobilization [28]. The duration of banking before thumb reconstruction via ectopic banking of bony phalanges from a nonreplantable amputated thumb should be no more than 2 weeks [101].

Functional milestones: At the last follow-up (24 months), a significantly different improvement was seen in all measured parameters for modified Viegas dorsal capsuloplasty for chronic partial injury of the scapholunate ligament in young athletes [103]. Long-term outcomes for arthrodesis in severe recurrent proximal interphalangeal joint contractures in Dupuytren's disease show high patient satisfaction [55]. Syndactyly reconstruction yields satisfactory subjective long-term outcomes [24]. Patients undergoing revision of residual deformities after primary surgery for Wassel-Flatt IV-D thumb duplication using a microsurgical free lateral great toe flap were followed up for 8–12 months with satisfactory appearance of the reconstructed thumbs [60]. Two years postoperatively, a patient with an ectopic nail on a hidden thumb duplication regained full range of movement of the hand [102].

Other Considerations: Secondary flexor tendon reconstruction includes delayed treatment and 1-stage and 2-stage reconstruction methods [1]. Long-term results following soft tissue reconstruction for Boutonniere finger deformity in rheumatoid arthritis are unreliable [2]. Recurrent or persistent Boutonniere finger deformity in rheumatoid arthritis is best treated with a salvage procedure [2]. The homodigital unipedicle neurovascular island flap is a safe and reliable flap for fingertip coverage [4]. A 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 [9]. The revision rate for radial polydactyly reconstruction trended upward over time despite maintenance of favorable scores on objective outcome measures [23]. Intermediate-term outcomes for arterial grafts in upper extremity vascular reconstruction are promising, with patency rates up to 100% reported [25]. No long-term outcomes studies exist for arterial grafts in upper extremity vascular reconstruction [25]. Recent literature has enhanced understanding of pathoanatomy and natural history of brachial plexus birth palsy, leading to improved care [27]. The time elapsed between injury and surgery is not an important risk factor for a good outcome in primary repair of Zone 2 flexor tendon injuries [28]. Further studies with long-term follow-up are needed to determine whether the grafted area in autologous matrix-induced chondrogenesis will maintain structural and functional integrity over time [48]. All flaps survived in the revision of residual deformities after primary surgery for Wassel-Flatt IV-D thumb duplication using a microsurgical free lateral great toe flap [60]. Reconstructive surgery was required in 15% of patients during the 10-year follow-up period after hand burns [100]. Two years postoperatively, a patient with an ectopic nail on a hidden thumb duplication remained free of local and distant disease with well-healed flaps [102].

Key Evidence

  • [L5] Current indications and methods, including delayed treatment and 1-stage and 2-stage reconstruction, are reviewed with future directions discussed. (10.1016/j.jhsa.2007.08.018)
  • [L5] Long-term results following soft tissue reconstruction are unreliable, and recurrent or persistent deformity is best treated with a salvage procedure. (10.1016/j.jhsa.2011.05.029)
  • [L4] Early surgery can be performed within the first 2 weeks if the patient is fit, the injury pattern is clear, and a reconstruction plan is established; otherwise, it is better to wait until 2 to 3 months to refine the surgical plan. (10.1177/1753193414540074)
  • [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. (10.1177/17531934231172081)
  • [L4] Reconstructive surgery produced significant functional improvements at 6 months which remained essentially unchanged at the 4.5-year follow-up. (10.1054/jhsb.1999.0265)
  • [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. (10.1016/j.jhsa.2016.04.020)
  • [L5] A thorough understanding of the complex anatomy and a working knowledge of the reconstructive options available are essential for successful outcomes. (10.5435/jaaos-d-18-00218)
  • [Case_report] Despite the non-anatomical reconstruction, no signs of inferior bone quality or risk of fracture developed, and the patient regained almost complete function. (10.1177/1753193417701061)
  • [L4] In this clinical series of 9 cases, the modified technique resulted in high flap survival rates with satisfactory functional outcomes. (10.1016/j.jhsa.2018.02.023)
  • [L4] The high risk of complications and reoperations associated with this technique should be considered when selecting from among possible alternative reconstruction methods. (10.1097/corr.0000000000003097)
  • [L3] We were unable to recognize a substantial clinical or radiological difference between the 2 surgical treatments in long-term outcome. (10.1016/j.jhsa.2012.11.016)
  • [Case_report] They note that while the patient had functional recovery, lack of recognition in more severe presentations may result in missed opportunities for reconstruction. (10.1016/j.jhsa.2013.04.021)
  • [L4] Although considered obsolete by many surgeons due to appearance, non-medical people do not consider the unattractive appearance to outweigh the functional outcome. (10.1177/1753193411406479)
  • [L5] Optimal outcomes require meticulous surgical technique combined with preoperative and postoperative hand therapy to preserve function and prevent contracture. (10.1016/j.jhsa.2014.07.032)
  • [L5] The pre-operative assessment and intraoperative findings of all thumb elements should be considered in surgical decision-making to define the methods of reconstruction. (10.1177/1753193418793579)
  • [L4] The method of soft-tissue reconstruction has no effect on functional outcome. (10.1302/0301-620x.96b5.32241)
  • [L4] The procedure does not require harvesting of a graft and is simple, though there are limited indications. (10.1177/1753193415593472)
  • [L2] The reconstruction using parallelogram flaps is a easier and more versatile treatment with better functions, less morbidity and better aesthetics. (10.1186/s13018-022-03214-1)
  • [L4] This procedure is mainly chosen by selected patients who refuse standard microsurgical thumb reconstruction because it requires a longer treatment period. (10.1016/j.jhsa.2013.02.030)
  • [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. (10.1177/17531934231220783)
  • [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. (10.1177/1753193417723310)
  • [L4] The procedure is recommended only as a salvage procedure. (10.1016/j.jhsa.2020.06.001)
  • [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. (10.1016/j.jhsa.2014.05.006)
  • [L4] Syndactyly reconstruction yields satisfactory subjective long-term outcomes. (10.1177/17531934251380997)
  • [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. (10.1016/j.jhsa.2012.12.009)
  • [L5] Recent literature has enhanced understanding of pathoanatomy and natural history, leading to improved care. (10.1016/j.jhsa.2009.11.026)
  • [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. (10.1177/17531934211024435)
  • [L5] Appropriate interventions and management of expectations will optimize limb appearance and function while avoiding unexpected sequelae. (10.5435/jaaos-d-20-00719)
  • [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. (10.1177/1753193421995697)
  • [L5] Reconstructive surgery for OBPL beyond primary nerve repair requires understanding and correcting pathophysiology and deformation, yet measurement of outcomes remains challenging. (10.1177/17531934221146860)
  • [L4] In appropriate patients, an improved aesthetic and functional outcome can be achieved. (10.1016/j.jhsa.2016.11.008)
  • [L5] Thumb deformities in rheumatoid arthritis are common and significantly compromise function; treatment is directed by the specific deformity type and joint involvement, with nonsurgical management for early stages and surgical reconstruction or salvage for advanced disease. (10.5435/00124635-200702000-00006)
  • [L4] Understanding the various differences in anatomy, physiology, mechanism of injury, surgical technique, and outcomes is crucial to obtaining the best possible result for the child and family. (10.1016/j.jhsa.2013.09.002)
  • [L4] Microsurgical techniques for severe hand injury management, including replantation and reconstruction, demonstrated significant improvements in early sensory function and daily activity capacity. (10.1186/s12891-025-09441-x)
  • [L4] Children with OBPP who had microsurgical reconstruction commonly reported pain. (10.1016/j.jhsa.2015.02.003)
  • [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. (10.1177/17531934251314640)
  • [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. (10.5435/00124635-199803000-00004)
  • [L4] This flap provides adequate soft tissue and good functional outcome compared with other salvage procedures. (10.1016/j.jhsa.2012.01.032)
  • [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. (10.1054/jhsb.1999.0199)
  • [Letter] They state that the stage is wide open for clinical, bench, and biomechanical research to test the theories to ascertain the most effective intervention science for the painful thumb. (10.1016/j.jht.2013.05.001)
  • [L5] Both intrinsic balancing techniques improved grasp, but only the House procedure restored hand kinematics approximating those of an intrinsic-activated hand. (10.1016/j.jhsa.2013.08.098)
  • [L4] The technique offers a simple, effective, and strong repair with minimal donor site morbidity and a good prognosis for recovery. (10.1016/j.jhsa.2012.12.021)
  • [L4] Longer follow-up and prospective randomized comparisons are needed to better define rates of revision, failure, and complications. (10.1016/j.jhsa.2010.04.005)
  • [L4] However, further studies with long-term follow-up are needed to determine whether the grafted area will maintain structural and functional integrity over time. (10.1007/s00167-010-1042-3)
  • [L4] The surgical procedure provides good functional outcomes and may reduce the need for prosthesis acceptance. (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. (10.1016/j.jhsa.2007.12.012)
  • [L5] Continued enhancement in immune modulation, surgical indication, patient selection, and posttransplant care is expected to make VCA a major milestone in reconstructive surgery. (10.1016/j.jhsa.2017.01.019)
  • [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. (10.1302/0301-620x.99b9.bjj-2017-0219.r1)
  • [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. (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. (10.1186/s13018-023-04480-3)
  • [L4] The long-term outcomes show high patient satisfaction, fairly rapid return to function with no requirement for revision surgery. (10.1177/1753193420960309)
  • [L3] This study shows that even though the range of wrist motion and the strength of the wrist and fingers are less than normal, hand function remains good. (10.1177/1753193416651574)
  • [L4] Regrettably, longterm functional follow-up of the patients is not available. (10.1177/1753193418805854)
  • [L4] The location of the perforator used differs from previous descriptions but is routinely and reliably located. (10.1016/j.jhsa.2021.08.016)
  • [L5] A rationale for a dynamic stabilization approach is presented based on the unique anatomy of the thumb. (10.1016/j.jht.2022.06.007)
  • [L4] All flaps survived and patients were followed up for 8–12 months with satisfactory appearance of the reconstructed thumbs. (10.1177/17531934231222400)
  • [L4] The use of a proximity sensor eliminates the need for forceful movements of the residual finger to use mechanical switches or levers and makes the operation more intuitive and easier to understand. (10.1177/17531934231209645)
  • [L4] Selection of the donor nerve must be carefully weighed against other treatment alternatives, considering the risk of donor nerve impairment and the potential narrowing of future reconstructive options. (10.1016/j.jhsa.2006.12.012)
  • [L4] Major advantages include confinement of the donor site to the ipsilateral extremity, no requirement for microsurgery, and improved cosmesis due to primary closure without a skin graft. (10.1016/j.jhsa.2018.06.012)
  • [L4] Mechanical solutions to minimize force required at the wrist to activate grip are still required. (10.1016/j.jht.2020.04.005)
  • [L4] Further radiographs prior to surgical treatment are unnecessary. (10.1177/1753193408097859)
  • [L1] There is wide disparity in scoring systems, definition of recurrence, and recording of complications, making critical comparison of techniques impossible. (10.1177/1753193410376286)
  • [L4] Routing of the EPL tendon through the first dorsal compartment allows reproduction of the action of thumb extension and abduction and restores thumb clearance from the palm. (10.1016/j.jhsa.2015.01.018)
  • [L5] The authors present fundamental muscle-tendon-joint mechanics studies that allow for single-stage surgical reconstruction of hand function and early postoperative activity-based training in patients with cervical spinal cord injuries. (10.1177/1753193419827814)
  • [L4] Improved strength of thumb reconstructions and reduced need for secondary surgery was also displayed. (10.1016/j.jhsa.2011.04.010)
  • [L5] Surgical reconstruction aims to create a stable thumb capable of satisfactory grasp and release by decreasing deformity, balancing muscle forces, and stabilising joints. (10.1177/1753193407087891)
  • [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. (10.1016/j.jht.2013.10.006)
  • [Case_report] The technique is capable of restoring good hand function in severe injuries with substantial phalangeal bone loss. (10.1016/j.jhsa.2008.04.025)
  • [L4] Extension strengths of the thumb and index finger of the operated hand were approximately 20% lower compared to the contralateral hand, yet clinical functional scores and range of motion were favourable. (10.1177/17531934241226949)
  • [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. (10.1177/17531934221116960)
  • [L4] However, magnetic resonance imaging indicates that the donor site is resurfaced with fibrous tissue. (10.1177/0363546507306465)
  • [L5] Sensation is the most important factor in thumb or fingertip repair, constituting 40% of the goal, while length and appearance account for 50%. (10.1177/17531934211051303)
  • [L5] Treatment options range from non-operative measures to various surgical procedures including cheilectomy, arthroplasty, and arthrodesis, with selection depending on disease stage and patient factors. (10.2106/00004623-199806000-00015)
  • [L4] Good functional outcomes, especially in the ability to oppose the thumb across the palm, patient satisfaction, and no complications demonstrate that this is both an effective and safe procedure. (10.1177/1753193413481303)
  • [L4] However, room still remains for improved thumb motion with both procedures. (10.1016/j.jhsa.2019.12.009)
  • [L3] Correction of the wrist deformity enables more ergonomic hand use and may help prevent shoulder pain. (10.1177/1753193412453412)
  • [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. (10.1177/1753193420983213)
  • [L5] Variation in methods of outcome measurement of thumb function suggests that consistency and efficacy of current methods are less than ideal; it may be appropriate to consider applying a standard global assessment of thumb function to all congenital conditions affecting the thumb. (10.1177/1753193415625146)
  • [L5] Surgical management is indicated for progressive, painful, unilateral deformity or leg-length discrepancy, while moderate nonprogressive deformity often does not require surgery. (10.5435/00124635-199803000-00003)
  • [L3] The study notes that while non-randomised, the technique appears better without an increased rate of rupture but with a shorter rehabilitation period. (10.1177/1753193408091570)
  • [L1] There is low level of evidence that both surgical and nonsurgical treatments provide clinically important improvements for recurrent Dupuytren contracture. (10.1177/1558944721994220)
  • [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. (10.1054/jhsb.1999.0225)
  • [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. (10.2106/00004623-199701000-00010)
  • [L4] Soft tissue releases offer advantages over bony procedures like arthrodesis and arthroplasty, particularly in patients with normal joint radiographs. (10.1016/j.jhsa.2007.06.011)
  • [L4] Bone resorption occurred in the digit reconstructed using the circumferential method seven months after surgery, though the true incidence remains unclear as radiographs are not commonly performed after such procedures. (10.1177/1753193412453413)
  • [L5] A majority of experts (83%) believe standardized long-term clinical follow-up is necessary, but no consensus exists on specific time points or the necessity of standardized radiological follow-up. (10.1177/17531934241247743)
  • [L4] Approximately 13% of syndactyly reconstructions require reoperation, with most occurring within 4 years of the primary procedure. (10.1016/j.jhsa.2024.08.012)
  • [L4] Reconstructive surgery was required in 15% of patients during the 10-year follow-up period after hand burns. (10.1016/j.jhsa.2017.02.006)
  • [L4] The duration of banking before thumb reconstruction should be no more than 2 weeks. (10.1016/j.jhsa.2022.06.027)
  • [L4] Two years postoperatively, the patient remains free of local and distant disease with well-healed flaps and regained full range of movement of the hand. (10.1177/1753193408101859)
  • [L4] At the last follow-up, a significantly different improvement was seen in all measured parameters and all patients could return to their original competitive activity, within 6 months after surgery. (10.1177/1753193420939490)

See Also

References

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

[3] Timing of surgical reconstruction for closed traumatic injury to the supraclavicular brachial plexus. Journal of Hand Surgery (European Volume). 2014. DOI: 10.1177/1753193414540074

[4] 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

[5] 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

[6] 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

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

[8] Functional reconstruction of the entire fifth metacarpal bone after en-bloc resection with a Y-shaped bone fusion to the fourth metacarpal: A case report. Journal of Hand Surgery (European Volume). 2017. DOI: 10.1177/1753193417701061

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

[10] Composite Reconstruction With Irradiated Autograft Plus Total Hip Replacement After Type II Pelvic Resections for Tumors Is Feasible but Fraught With Complications. Clinical Orthopaedics & Related Research. 2024. DOI: 10.1097/corr.0000000000003097

[11] 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

[12] Isolated Lower Brachial Plexus (Klumpke) Palsy With Compound Arm Presentation: Case Report. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2013.04.021

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

[14] Acute Surgical Management of Hand Burns. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.07.032

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

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

[17] Collateral ligament repair augmented by an A2 pulley flap for chronic ligament rupture of the finger metacarpophalangeal joint. Journal of Hand Surgery (European Volume). 2016. DOI: 10.1177/1753193415593472

[18] 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

[19] 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

[20] 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

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

[22] 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

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

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

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

[26] 11. Amputations. 2013.

[27] Current Concepts in the Management of Brachial Plexus Birth Palsy. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2009.11.026

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[29] The Spastic Upper Extremity in Children: Multilevel Surgical Decision-making. Journal of the American Academy of Orthopaedic Surgeons. 2021. DOI: 10.5435/jaaos-d-20-00719

[30] 9. Hand Surgery. 2013.

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

[32] Microsurgical reconstruction of obstetric brachial plexus palsy: ongoing challenges and future directions. Journal of Hand Surgery (European Volume). 2023. DOI: 10.1177/17531934221146860

[33] Distraction Lengthening Following Vascularized Second Toe Transfer for Isolated Middle Finger Reconstruction. The Journal of Hand Surgery. 2017. DOI: 10.1016/j.jhsa.2016.11.008

[34] Reconstruction of the Rheumatoid Thumb. Journal of the American Academy of Orthopaedic Surgeons. 2007. DOI: 10.5435/00124635-200702000-00006

[35] Pediatric Replantation. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2013.09.002

[36] Application of microsurgical techniques in severe hand injury management: a retrospective analysis of clinical data. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-09441-x

[37] Pain in Children Following Microsurgical Reconstruction for Obstetrical Brachial Plexus Palsy. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2015.02.003

[38] 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

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

[40] 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

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

[42] Response to “The CMC challenge continues”. Journal of Hand Therapy. 2013. DOI: 10.1016/j.jht.2013.05.001

[43] Intrinsic Hand Muscle Function, Part 2: Kinematic Comparison of 2 Reconstructive Procedures. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2013.08.098

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

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

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

[48] Mid‐term results of Autologous Matrix‐Induced Chondrogenesis for treatment of focal cartilage defects in the knee. Knee Surgery, Sports Traumatology, Arthroscopy. 2010. DOI: 10.1007/s00167-010-1042-3

[49] 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

[50] 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

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

[52] 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

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

[54] 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

[55] 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

[56] An objective functional evaluation of the flexor carpi ulnaris set of triple tendon transfer in radial nerve palsy. Journal of Hand Surgery (European Volume). 2016. DOI: 10.1177/1753193416651574

[57] The use of a free groin flap to reconstruct a dorsal hand skin defect in the replantation of multi-finger amputations. Journal of Hand Surgery (European Volume). 2018. DOI: 10.1177/1753193418805854

[58] Reconstruction of Digit Soft Tissue Defects With the Fourth Common Digital Artery Perforator Flap. The Journal of Hand Surgery. 2022. DOI: 10.1016/j.jhsa.2021.08.016

[59] Dynamic stabilization of the painful thumb: A historical and evidence-informed synthesis. Journal of Hand Therapy. 2022. DOI: 10.1016/j.jht.2022.06.007

[60] 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

[61] Novel prosthesis with proximity sensor for upper extremity phocomelia. Journal of Hand Surgery (European Volume). 2023. DOI: 10.1177/17531934231209645

[62] Heterotopic Nerve Transfers: Recent Trends With Expanding Indication. The Journal of Hand Surgery. 2007. DOI: 10.1016/j.jhsa.2006.12.012

[63] The Fascia-Only Reverse Posterior Interosseous Artery Flap. The Journal of Hand Surgery. 2019. DOI: 10.1016/j.jhsa.2018.06.012

[64] 3D-printed custom-designed prostheses for partial hand amputation: Mechanical challenges still exist. Journal of Hand Therapy. 2021. DOI: 10.1016/j.jht.2020.04.005

[65] Chapter 29 Hand/Carpal Fractures and Dislocations. 2021.

[66] Resection of a giant cell tumour of the proximal phalanx and reconstruction by iliac crest graft. Journal of Hand Surgery (European Volume). 2009. DOI: 10.1177/1753193408097859

[67] The outcome of surgical treatments for primary Dupuytren’s disease – a systematic review. Journal of Hand Surgery (European Volume). 2010. DOI: 10.1177/1753193410376286

[70] Rerouting Extensor Pollicis Longus Tendon Transfer. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2015.01.018

[71] Reach out and grasp the opportunity: reconstructive hand surgery in tetraplegia. Journal of Hand Surgery (European Volume). 2019. DOI: 10.1177/1753193419827814

[72] Posttraumatic Reconstruction of the Hand—A Retrospective Review of 87 Toe-to-Hand Transfers Compared With an Earlier Report. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2011.04.010

[73] THE SRGICAL MANAGEMENT OF THUMB DEFORMITY IN CEREBRAL PALSY. Journal of Hand Surgery (European Volume). 2008. DOI: 10.1177/1753193407087891

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

[75] Nonvascularized Autogenous Bone Graft for Extensive Phalangeal Bone Loss: Case Report. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2008.04.025

[76] Clinical outcomes of extensor indicis proprius tendon transfer for extensor pollicis longus tendon rupture. Journal of Hand Surgery (European Volume). 2024. DOI: 10.1177/17531934241226949

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

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3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.