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Reconstructive Surgery

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

128 citationsUpdated Sep 2026

Overview

Reconstructive decision making in elbow, wrist, and hand surgery is currently based on surgeon experience and popular consensus rather than excellent evidence [3]. 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 [5]. Surgical intervention for burned hands should follow the standard reconstructive ladder and can involve several techniques from simple to complex [14]. The choice of reconstruction for soft tissue coverage of the digits and hand depends primarily on the amount of volar skin available, the patient's functional demands, and the surgeon's expertise [40]. Combined reconstruction strategies should be considered based on defect characteristics, with acceptable complication rates and good functional recovery [2]. 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 [11].

Specific indications guide the selection of reconstructive methods. Propeller perforator flaps offer advantages including no need for microvascular anastomoses, replacing like-with-like, and faster functional rehabilitation, which can reduce the indication for free flaps in well-selected cases [64]. Free flap reconstructions offer critical advantages over non-microsurgical techniques, including early mobilization and appropriate coverage with acceptable donor morbidity [23]. Pedicle perforator flaps are recommended for medium defects and free flaps for large defects to achieve optimal functional and aesthetic outcomes [21]. The risk of adverse events in local flap reconstruction for digital soft tissue defects is acceptable in all flap types, with an overall rate of 5.4% and reoperations needed in approximately 2% of cases [30]. Vascular complications of flap procedures and replantation surgery in the upper extremity can be minimized by employing appropriate indications and thorough preoperative planning [70]. The need for refinement and secondary surgery should be taken into consideration during the initial flap selection process [61].

Patients with firework-related hand injuries often require reconstruction rather than repair, and many will require secondary procedures, making prevention the best treatment [1]. Compared with no reconstruction, any procedure is of benefit for traumatic thumb loss [29]. Replantation surgery can be achieved only if the basic principles and indications of replantation surgery are adhered to [58]. There are currently no criterion standard measures to evaluate the consequences of reconstructive arm/hand surgery for tetraplegia [12]. Continued enhancement in immune modulation, surgical indication, patient selection, and posttransplant care is expected to make vascularized composite allografts a major milestone in reconstructive surgery [145].

Anatomy & Pathophysiology

General Principles & Functional Anatomy

The hand serves as both an information-gathering organ and an organ of execution [35]. Its efficiency depends on the stability and mobility of the proximal limb joints, with combined wrist and forearm movements positioning the hand for grasping [35]. During gripping, the wrist is typically flexed when close to the trunk and extended when placed at a distance [35]. The open hand forms a balanced, graceful oval along its longitudinal axis, with a convex dorsal aspect that is aesthetically important and a concave palmar surface that is functional [35]. The hand comprises 19 bones, 17 articulations, and 19 intrinsic muscles, alongside a similar number of tendons activated by forearm muscles [35]. While the functional importance of the hand is often underestimated, there is increasing recognition of this challenging reconstructive domain [19]. Painless, full hand function requires seamless integration of joints, muscles, and nerves to complete basic tasks [16]. The primary treatment goal is achieving power pinch and grasp with durable, sensate coverage [18]. The adaptability of a mobile finger unit results from the equiangular spiral course traversed by the sensate fingertip [18]. Hand grip strength cannot exceed the strength of wrist extensors, which must neutralize the flexor tendons' ability to flex the wrist [18]. Injured hands demonstrate a functional cascade where wrist extensor loss causes wrist flexion, leading to finger flexion, edema, and proximal interphalangeal joint flexion [18]. The hand is remarkably mobile and malleable, conforming to objects for grasping or study [35]. Located at the extremity of the upper limb, the hand gives the limb its importance and uniqueness as its functional vector [35].

Osseous Skeleton

The hand and wrist skeleton consists of 27 bones, 19 of which are long bones [43]. The skeleton is divided into five rays, each forming a polyarticulated chain of metacarpals and phalanges [43]. Each metacarpal base articulates with the distal carpal row [43]. The radioulnocarpal articulation possesses two axes of movement, supplemented by a third axis of pronation and supination from the forearm [43]. These three wrist axes permit the hand to assume any spatial configuration [43]. The radial ray is the shortest, comprising only a metacarpal and two phalanges [43]. The trapezium is angled anteriorly out of the carpal plane, creating a 45-degree angle between the first and second metacarpals in the sagittal plane [43]. The thumb metacarpal is the shortest, while the index metacarpal is the longest [43]. The proximal and middle phalanges of the long and ring fingers are longer than those of the index finger [43]. In flexion, digital extremes converge toward the thumb pulp for pinch or the thenar eminence base for power grip [43]. More ulnar digits deviate more obliquely as they approach the palm [43]. The two ulnar metacarpals, particularly the fifth, exhibit slightly more flexion–rotation mobility to compensate for their lack of length [43]. The hand skeleton presents longitudinal and transverse concavities, forming a cup shape with palmar concavity when the thumb is placed next to the index finger [43]. The transverse palm axis is oblique, more distal at the index metacarpophalangeal joint and more proximal at the fifth metacarpophalangeal joint [43]. This transverse axis forms an acute angle of approximately 75 degrees with the longitudinal axis [43]. Epiphyseal plates are located at the proximal ends of the phalanges and first metacarpal, and at the distal ends of the other metacarpals [43]. The index metacarpal is the most firmly fixed [91]. The ring metacarpal has about 10 degrees of flexion and extension mobility [91]. The fifth metacarpal has a flexion–extension range of approximately 20 degrees [91]. The second to fifth metacarpals are bound by fibrous structures, the most distal being the deep transverse intermetacarpal ligament [91]. This ligament is better termed the interglenoid ligament because it ties together the anterior “glenoid ligaments” of the metacarpophalangeal articulations, known as volar plates [91]. The metacarpophalangeal articulations serve as keystones of the longitudinal arches, with their thick anterior glenoid capsules (volar plates) preventing hyperextension [91]. Metacarpophalangeal joint stability is essential for supporting both the longitudinal and transverse metacarpal arches [91]. The thumb ray is more mobile, shorter, and more proximal than the others, allowing it to project anterior to the palm plane to oppose the other four rays [43]. Flexion axes are arranged so that flexion of all metacarpophalangeal and proximal interphalangeal joints causes fingers to converge toward the scaphoid [106]. The third metacarpal acts as the hand's axis and a landmark for wrist movements [106]. The metacarpophalangeal joints lie on a transverse line beginning in the distal palmar crease on the ulnar side and running into the proximal crease on the radial border [106].

Musculotendinous Anatomy

Digital posture control requires a complex balance of extrinsic and intrinsic muscle forces [41]. Extrinsic muscles originate outside the hand and insert on the hand or carpus, whereas intrinsic muscles have both origin and insertion within the hand [41]. Extrinsic extensors traverse six fibroosseous retinacular compartments at the wrist [41]. Compartment Contents: * First: Abductor pollicis longus and extensor pollicis brevis [41]. * Second: Extensor carpi radialis longus and extensor carpi radialis brevis [41]. * Third: Extensor pollicis longus, which turns abruptly radialward about Lister tubercle [41]. * Fourth: Extensor indicis proprius, lying deep to the four extensor digitorum communis tendons [41]. * Fifth: Extensor digiti quinti [41]. * Sixth: Extensor carpi ulnaris, inserting at the base of the little finger metacarpal [41].

The extensor digitorum communis tendons of the middle, ring, and little fingers are tethered by juncturae tendinum over the dorsum of the hand proximal to the metacarpophalangeal joint [41]. Digital extensor tendons are stabilized over the midline of the metacarpophalangeal joint by attachment to sagittal band fibers [41]. These fibers insert onto the volar proximal phalanx and lateral borders of the volar plate [41]. Rupture or attenuation of sagittal band fibers allows the extrinsic extensor tendon to sublux ulnarly, causing ulnar deviation of the finger [41]. The extrinsic finger flexors are the flexor digitorum profundus and flexor digitorum superficialis [41]. The flexor digitorum profundus inserts on the proximal volar aspect of the distal phalanx [41]. The flexor digitorum superficialis acts as a flexor of the proximal interphalangeal and metacarpophalangeal joints [41].

There are seven interosseous muscles: four dorsal and three volar [88]. The dorsal interossei are abductors, while the volar interossei are adductors [88]. The middle finger has two dorsal interossei and no volar interossei because the central hand axis lies within it [88]. Each dorsal interosseous muscle, except the third, has two heads [88]. The superficial head abducts and weakly flexes the proximal phalanx [88]. The deep head forms a lateral tendon (lateral band) at the metacarpophalangeal joint level [88]. The deep head flexes and weakly abducts the proximal phalanx while extending the middle and distal phalanges [88]. Transverse fibers arch dorsally from each lateral band to join over the finger dorsum, flexing the proximal phalanx [88]. Oblique (spiral) fibers from the lateral bands sweep over the distal third of the proximal phalanx to insert on the lateral tubercles at the base of the middle phalanx [88]. These oblique fibers extend the middle phalanx at the proximal interphalangeal joint [88]. The lateral bands join the lateral slips of the extensor tendon to form the conjoined lateral band [88]. The two conjoined lateral bands unite at the distal third of the middle phalanx to form the terminal tendon [88]. The terminal tendon inserts at the base of the distal phalanx to extend it [88]. The flexor digiti quinti brevis is structurally and functionally similar to the deep head of the dorsal interossei, forming the ulnar lateral band of the little finger [88]. The three volar interossei arise from adjacent surfaces of contiguous metacarpal shafts [88]. They form the ulnar lateral band of the index finger and the radial lateral bands of the ring and little fingers [88]. The abductor digiti quinti and flexor digiti quinti brevis are similar in structure and function to the superficial and deep heads of the dorsal interossei, respectively [88]. The opponens digiti quinti arises from the pisohamate ligament and hook of the hamate, inserting onto the ulnar side of the fifth metacarpal diaphysis [88].

The flexor digitorum profundus originates from the proximal ulna and interosseous membrane [99]. It and the flexor pollicis longus form the deep volar forearm compartment [99]. The flexor pollicis longus tenosynovial sheath is continuous with the radial bursa [99]. The little finger tenosynovial sheath is continuous with the ulnar digital bursa [99]. In some patients, the radial and ulnar bursae communicate, allowing a horseshoe abscess to spread between the thumb and little finger if infection occurs in either flexor tendon sheath [99]. The lumbricals originate from the radial side of the index, middle, ring, and little fingers in the palm [99]. The flexor digitorum profundus of the index and middle fingers is innervated by the anterior interosseous branch of the median nerve [99]. The profundus of the ring and little fingers is innervated by the ulnar nerve [99]. The flexor digitorum superficialis has two heads: a radial head from the proximal radius shaft and a humeral ulnar head from the medial humeral epicondyle and coronoid process [99]. In the proximal finger, the superficialis tendon bifurcates around the profundus at the beginning of the A2 pulley [99]. The superficialis tendon slips reunite distally at the Camper chiasm, with half the fibers staying ipsilateral and half crossing contralaterally [99]. The entire flexor digitorum superficialis receives median nerve innervation [99]. Its primary function is digital flexion at the proximal interphalangeal joint [99]. The flexor pollicis longus has two heads: a radial head from the proximal radius and interosseous membrane, and an accessory head from the ulnar coronoid process and medial humeral epicondyle [99]. It inserts into the proximal base of the thumb distal phalanx and is innervated by the anterior interosseous branch of the median nerve [99]. The flexor pollicis longus flexes both the interphalangeal and metacarpophalangeal joints of the thumb [99]. As flexor tendons pass distal to the metacarpal neck, they enter the fibroosseous tunnel, or digital flexor sheath [99]. This tunnel extends distally to the proximal aspect of the distal phalanx [99]. The sheath consists of annular pulleys providing mechanical stability and cruciate pulleys providing flexibility [99]. Pulley Locations: * A1, A3, A5: Located over the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints, respectively [99]. * A2, A4: Situated over the middle portion of the proximal and middle phalanges [99].

The A2 and A4 pulleys are most essential for maintaining flexor tendon mechanical advantage [99]. The tenosynovium lining the tunnel supplies nutrition and lubrication to poorly vascularized flexor tendons [99]. Within the sheath, tendon vascularity is supplied via the vincula system: vinculum longus and brevis [99]. The resting finger posture should be observed; disruption of the normal cascade of increasing flexion from index to little finger in relaxed fingers suggests tendon disruption [99]. If the index finger remains extended at rest, its flexor tendons are severed [99].

Vascular Anatomy

Thumb arteries vary in size and number, making surgical reconstruction delicate [93]. Common palmar artery variations are schematized by dividing the thumb into three segments defined by the metacarpophalangeal and interphalangeal flexion creases [93]. The “princeps pollicis” artery, a terminal branch of the radial artery, crosses the first intermetacarpal space, runs along the ulnar side of the first metacarpal and volar adductor muscle surface [93]. It emerges onto subcutaneous palmar tissue at the metacarpophalangeal joint cutaneous flexion crease level [93]. The princeps pollicis divides into two terminal rami, the collateral palmar arteries of the thumb, which run symmetrically along the digital tunnel with equal caliber [93]. A deep arcade in the flexor tendon joins these arteries at the distal first phalanx metaphysis level [93]. Only 15% of anatomical dissections fall into the classical palmar artery layout category [93]. In the second thumb segment, the main artery is the ulnar collateral artery [93]. The subtendinous anastomosis at the first phalanx neck level acts as a “moderator” between the two arteries [93]. If the palmar ulnar collateral artery is absent, the dorsal artery takes its place via a branch through the subtendinous arcade [93]. In the pulp segment, the two arteries are of similar size and run through the thick fatty subcutaneous padding [93]. Dorsal thumb arteries originate from palmar arteries (princeps, commissural, or superficial arcade anastomoses) at the first metacarpal level [93].

Classification

SATT: The SATT classification system for open hand injuries identifies the severity of the initial injury and determines whether the involved parts are viable [205]. It considers anatomical localisation (isolated vs. extended) and topography (volar vs. dorsal) to direct management [205]. The system also takes into account the type of injury (sharp vs. crush-avulsed) to ensure the hand will be functional to the full extent possible [205].

Waikakul: The Waikakul classification of degloving injuries categorizes Type I as severely damaged skin requiring debridement and flap or graft [240]. Type II involves moderate damage with subcutaneous veins present, managed by arterialization of the venous system [240]. Type III is defined by observed venous backflow and is managed by venous anastomosis only [240].

Tajima: The Tajima classification of circumferential open injuries defines Type 1 as superficial to deep fascia [240]. Type 2 extends superficial to periosteum [240]. Type 3 involves bone affected [240].

Radial Polydactyly: A proposed new classification system supplements Wassel's classification by providing clear guidance on surgical methods and required surgeon expertise levels [92]. This system facilitates treatment decision-making and communication [92]. A modified classification is also proposed as a practical and utilitarian scheme for nomenclature that may assist comparison of treatment outcomes and individual cases [141].

Limb Salvage Failure: The modified evidence-based classification system for failure of limb salvage after reconstructive surgery for bone tumours provides specificity for endoprosthetic, biological, and paediatric failures [87]. It corrects weaknesses of earlier systems by allowing for better interpretation of outcomes following reconstructive surgery [87].

Soft Tissue Sarcoma: The American Joint Committee on Cancer/International Union Against Cancer classification is most commonly employed for soft tissue sarcoma of the extremities [198]. Staging includes the assessment of tumor size, nodal status, presence of metastases (TNM-status), and pathological grading of the tumor [198]. In the 2010 modification, patients with regional lymph node involvement are considered stage III instead of stage IV [198]. This 2010 modification has been criticized for not implementing some primary tumor classification features of the previous 2002 version [198].

Tubiana: The Tubiana classification system categorizes the total passive extension deficit of each ray in 4 stages [236]. Stage I is defined as 0–45° of passive extension deficit [236]. Stage II is defined as 46–90° of passive extension deficit [236]. Stage III is defined as 91–135° of passive extension deficit [236]. Stage IV is defined as 136–180° of passive extension deficit [236].

Clavien-Dindo: The Clavien-Dindo classification of surgical complications adapted for orthopedic surgery includes 5 severity grades based on the treatment required to manage the complication and any long-term morbidity [180].

Lister: The Lister classification is used to classify distal digital amputations [206].

Other Considerations: A proposed new classification for major upper limb deglovings defines these injuries as deglovings that involve multiple adjacent digits in-continuity, or degloving of the hand [240]. The classification of ring avulsion injuries needs modification to clarify the differences between total avulsion of the soft tissue alone and avulsion with amputation [125].

Clinical Presentation

Clinical evaluation of the injured or dysfunctional hand and wrist can be a daunting task, necessitating a systematic approach to the physical examination due to the high density of structures within a small space [16]. Patients often struggle to accurately describe their symptoms and may incorrectly attribute pathology to a perceived deficit, whether real or imagined [16]. While diagnostic tests such as imaging and serum laboratory studies are useful in determining pathologic processes, they can be expensive, time-consuming, and often nonspecific [16]. Consequently, a careful physical examination is essential to direct care and future testing if indicated [16].

History: The history should include details of the accident, the patient’s age, occupation, leisure activities, and handedness [158]. Thorough assessment is important in the initial examination [158]. Superficial injuries and severe fractures are obvious, but deeper injuries are often poorly disclosed [158]. Obtaining a medical history with particular attention to documented diabetes and/or collagen vascular disease is very important [153]. A habit of smoking will have an impact on the clinical presentation of hand vascular disorders [153].

Inspection and Palpation: The initial examination should assess circulation, soft-tissue cover, bones, joints, nerves, and tendons [158]. The physical 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 [153]. The warmth of the fingers is important in the physical examination [153]. Pulses at the elbow and wrist should be felt during the physical examination [153]. Sensation plays a role in the physical examination, with the potential for sympathetic overactivity in the presence of nerve compression [153].

Vascular Assessment: Doppler ultrasound plays a very important role in the examination of the patient with a vascular disorder [153]. An Allen test can be performed, but performing a similar exam with a pencil Doppler may yield much more information [153]. 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 [153]. Surgeons must view vascular studies themselves because the radiologist or vascular specialist may or may not see the lesion [153]. Color-flow ultrasonography can show real-time flow and be used to evaluate an anastomosis, but is of primary use in the venous system [153].

Special Tests and Indices: Cold stress testing gives a measure of the vascular system’s ability to recover from exposure to cold [153]. A prolonged rewarming response in cold stress testing is often seen in women and can be diagnostic of Raynaud’s [153]. Smokers often have a delayed rewarming response in cold stress testing [153]. The digital-brachial index is the ratio of the blood pressure as measured in the brachial artery and the finger [153]. A digital-brachial index value below 0.7 designates a significant occlusive problem somewhere in the forearm or hand [153]. Blood flow in the capillary bed can be measured by laser Doppler flowmetry, which gives a quantitative measurement of blood flow at skin level [153]. Laser Doppler flowmetry equipment is quite expensive and not available to most practitioners [153]. Nail fold capillaroscopy shows morphology and flow at the capillary level but is not of practical use for most surgeons [153]. Many sophisticated tests are difficult for the practicing surgeon to perform and do not add much to decision making in terms of patient management [153].

Investigations

Clinical Examination and Evaluation

A careful physical examination is essential to direct care and future testing, as diagnostic tests such as imaging and serum laboratory studies can be expensive, time-consuming, and often nonspecific [16]. A systematic method is essential for approaching the physical examination of the hand and wrist due to the high density of structures in a small space [16]. The pre-operative assessment and intraoperative findings of all thumb elements should be considered in surgical decision-making to define the methods of reconstruction [32]. An algorithm based on anatomical considerations and functional outcomes can guide the plastic surgeon in dealing with complex situations [17]. A thorough understanding of the complex anatomy and a working knowledge of the reconstructive options available are essential for successful outcomes in extensor tendon reconstruction [25].

Imaging Modalities

MRI: High-resolution MRI is a reliable method of characterizing the anatomy of proximal interphalangeal joint structures and could be a useful clinical tool in determining reconstructive options [60]. In Wassel Type IV duplicated thumbs, MRI identified the cartilaginous configuration precisely, which assisted in choosing the correct site to perform osteotomies and eliminated the need for secondary operations [182]. Magnetic resonance imaging indicates that the donor site is resurfaced with fibrous tissue after autologous osteochondral mosaicplasty [176]. In Dupuytren's disease, MRI is probably most useful in identifying additional pathology such as flexor tendon bowstringing [132]. It may also provide a quantitative noninvasive measure of cellularity of affected areas, which is an index of biologic activity [132]. However, 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 [132].

CT Angiography: CT angiography can be used for preoperative evaluation of recipient vessels prior to microsurgical flap transfer [48]. It can also identify transected arteries and collateral blood flow patterns in acute upper extremity penetrating injuries [48].

Doppler Imaging: An 8-MHz Doppler tone assessment may be used to identify superficially displaced neurovascular bundles when Dupuytren cords lie beneath soft fleshy prominences, but false-negatives are possible [132]. Doppler imaging is a promising improvement for identifying palmar structures, but higher resolution imaging technology is needed [132].

Other Considerations: A new technique of quantifying the radiographic divergence of the border rays of the cleft demonstrates improved alignment at long-term follow-up in central ray deficiency [244].

Long-term Follow-up and Surveillance

A majority of experts (83%) believe standardized long-term clinical follow-up is necessary for brachial plexus birth palsy, but no consensus exists on specific time points or the necessity of standardized radiological follow-up [217]. 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 [6]. All parameters showed the greatest magnitude of improvement between preoperative measurements and 1 year of follow-up in moderate glenohumeral joint deformity in brachial plexus birth injury [247].

Treatment

General Principles and Planning

Reconstructive decision-making for tendon versus nerve transfers in the elbow, wrist, and hand is currently based on surgeon experience and popular consensus rather than excellent evidence [3]. The choice of flap should be selected based on wound characteristics and reconstructive needs, ideally without being influenced by the availability of microsurgical expertise or operating room resources [146]. Free flap soft tissue reconstruction should be selected early in the treatment algorithm if a better end result can be anticipated, as it allows for early coverage with composite reconstruction of all damaged or missing tissues and early mobilization to restore function [234]. Optimal functional and aesthetic outcomes in upper limb soft tissue reconstruction 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 [44]. The outcome of the initial debridement, repair, soft tissue coverage, and hand therapy greatly influences the need for secondary procedures following mutilating hand injuries [136]. Conversely, the method of soft-tissue reconstruction has no effect on functional outcome in interscapulothoracic resection of shoulder tumours [51].

Mangled Extremity and Trauma

The primary goal in managing the patient with a mangled upper extremity is to preserve life [42]. The quality of wound débridement dictates the outcome of limb salvage in mangled upper extremity injuries [42]. Thoughtful staged surgical planning is necessary to avoid limiting surgical options for reconstruction of the mangled upper extremity [42]. Successful reconstruction of the mangled upper extremity is largely based upon the outcomes of the initial surgical treatment that in turn is dependent on the adequacy of débridement [131]. Critical aspects of successful reconstruction of mangled injuries 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 [120]. Mangling injuries of the hand and upper extremity involve multiple critical structures and nearly always lead to significant disability, both directly and through their psychosocial impact [133]. The "one wound–one scar" concept describes how a scar will form from the skin down through bone and compromise the function of all structures involved in a mangling injury [133]. General principles for managing mangling injuries include complete debridement of devitalized tissue, restoration of good vascularity, rigid skeletal fixation while minimizing additional soft tissue injury, stable vascularized soft tissue coverage, timely intervention, comprehensive rehabilitation, and secondary procedures as needed [133]. Early complete debridement and immediate reconstruction with free tissue transfer enable early hand therapy, earlier return to function, and improved outcomes compared to delayed reconstruction for upper limb defects [10]. Patients with firework-related hand injuries often require reconstruction rather than repair, and many will require secondary procedures [1]. Combined reconstruction strategies should be considered based on defect characteristics for severe hand injuries, with acceptable complication rates and good functional recovery [2]. In the presence of an amputation, meticulous surgical technique, methodical surgical planning, and a thorough understanding of the biomechanics of the hand can result in functional limb salvage [42]. Vein interposition graft from the digital artery to the radial artery within the anatomic snuff box can facilitate thumb replantation or revascularization [42].

The decision to amputate or salvage a severely injured lower extremity relies on the expertise of the orthopedic surgeon and input from subspecialty colleagues, as limb salvage scores have proved to have little clinical utility [138]. Current data suggest that the results of limb reconstruction are equal to those of amputation following severe lower extremity trauma [138]. Amputation is a reconstructive procedure that should provide the patient with the best possible residual limb to form a robust foundation for the fitting of a prosthesis and the return of optimal function [140]. Healing by secondary intention is not advised in the presence of exposed nonvascularized structures such as bone, hardware, and tendons [214]. Secondary healing of small wounds over muscle or fascia may be appropriate if the medical status does not permit more complex reconstruction methods [214].

Replantation and Revascularization

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 [137]. 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 [137]. 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 [137]. Replantation at levels proximal to the distal forearm may be considered in children or for aesthetic reasons despite poor functional outcomes in adults [137]. Individual patient consideration is necessary to determine if replantation is indicated in distal amputations of the digits [42].

The preferred method of anesthesia for replantation is axillary or supraclavicular block because this technique provides a sympathetic block resulting in vasodilation [137]. 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 arteries, repair of nerves, and anastomosis of veins [137]. Two veins should be repaired for each artery repaired during replantation [137]. Fasciotomies of all muscle compartments should be performed at the time of replantation for injuries proximal to the distal forearm [137]. Patients 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 [137]. If vascular damage is found during replantation, a larger segment of the vessel should be resected and a vein graft interposed [137]. If failure 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 [137].

Anticoagulation should be given in the perioperative period after replantation to diminish the likelihood of anastomosis thrombosis [137]. Low-molecular-weight dextran for 5–7 days and aspirin are among the recommended anticoagulation regimens after replantation [137]. Vasospastic agents such as nicotine, caffeine, theophylline, and theobromine should be restricted for the first few weeks after replantation or revascularization [137]. The patient should be placed on a broad-spectrum antibiotic for 5–7 days after replantation [137].

Approximately 85% of replanted parts remain viable [137]. Sensory recovery with two-point discrimination of 10 mm or less occurs in approximately 50% of adults after replantation [137]. Patients with viable replanted or revascularized parts often complain of cold intolerance during the first 2 or 3 years after replantation [137]. 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 [119]. Experience dictates that satisfactory functional results in replantation can be achieved only if the basic principles and indications of replantation surgery are adhered to [58].

Thumb 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 [11]. The Krukenberg procedure is considered obsolete by many surgeons due to appearance, but non-medical people do not consider the unattractive appearance to outweigh the functional outcome [45]. An 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 [57]. Flap survival was 100% and functional improvement with near normal appearance was obtained in reconstructed thumbs using microsurgical techniques for partial thumb defects [134]. 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 [62]. Effective management of thumb hypoplasia requires an understanding of the embryology, epidemiology, classification, presentation, and management options [74].

Fingertip and Digital Defects

At a long-term follow-up, the 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 [9]. Free flap reconstructions offer critical advantages over non-microsurgical techniques for soft-tissue defects in digits, including early mobilization and appropriate coverage with acceptable donor morbidity [23]. 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 [126]. The reversed vascularized pedicled forearm flap provides adequate soft tissue and good functional outcome compared with other salvage procedures for complete degloved digits [123]. 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 [251]. No conclusive evidence exists in favor of an immediate versus a primary, early or delayed emergency reconstruction for post-traumatic finger reconstruction using toe-to-hand transfer [230]. A pinch reconstruction by hand-to-hand finger transfer associated with hallux transfer provided a satisfactory functional result in a patient with severe frostbite injury who refused any cosmetic prosthesis [202].

Soft Tissue Coverage and Flaps

Advances in microsurgery have provided improved thin, pliable, durable flaps that offer cosmetic reconstructive options for soft tissue defects of the hand [135]. The widespread availability of skin substitutes and the advent of negative pressure wound therapy provide adjunctive and alternative options to traditional reconstructive techniques for treating soft tissue defects of the hand [233]. Despite the advent of microsurgery and skin substitutes, pedicled abdominal flaps remain relevant for specific indications including patient/facility factors deterring microsurgery, absence of recipient vessels, prior surgical use of vessels, need to preserve major vessels, and large multi-surface wounds [144]. 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 [50]. In a clinical series of 9 cases, the reverse flow shunt restricted arterialized venous free flap resulted in high flap survival rates with satisfactory functional outcomes [27]. The main advantages of propeller perforator flaps, including no need of microvascular anastomoses, replacing like-with-like, and faster functional rehabilitation, can reduce the indication for free flaps in well-selected cases [64]. NPWT can help build a layer of granulation tissue over structures that would have precluded immediate skin grafting, such as tendon or bone, facilitating subsequent closure with skin grafting or healing by secondary intention [250]. The systematic review of venous flaps for coverage of traumatic soft tissue defects of the hand included 756 flaps from 45 retrospective case series, with common mechanisms of injury being burns, crush injury, and traumatic amputations [34].

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 [4]. The metacarpophalangeal joint extensor tendon subluxation reconstructive stabilization technique mimics normal anatomy with minimal disruption to local soft tissue structures and provides biomechanical advantages over previously described techniques [53]. 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 [193]. 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 [117]. Most patients are at least moderately satisfied with the improvement in function achieved by reconstructive surgery for complete lesions of the brachial plexus in adults [47].

After the first operation for upper limb functional restoration in old and complete brachial plexus paralysis, an arm support is provided for the non-paralyzed arm, and the patient’s activities are restricted for 4 weeks [249]. Following the second operation for upper limb functional restoration in old and complete brachial plexus paralysis, the elbow is fixed at 90° using a long back slab splint, and the forearm is elevated for the first few postoperative days [249]. First movements of the reinnervated transferred muscle usually occur at 4–8 months postoperatively in upper limb functional restoration for brachial plexus paralysis [249]. After the third operation for upper limb functional restoration in old and complete brachial plexus paralysis, a dorsal back slab is applied for three weeks at 60° elbow flexion, 30° wrist flexion and 60° MPs flexion [249].

Bone and Joint Reconstruction

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 [7]. There was no substantial clinical or radiological difference between radial shortening osteotomy and vascularized bone graft in long-term outcome for Kienböck disease [13]. The reverse metacarpal bone flap procedure is recommended only as a salvage procedure for the treatment of segmental bone defects of the proximal phalanges [63]. En-bloc resection and reconstruction using a non-vascularized toe phalanx may be preferred as a surgical alternative for giant cell tumour of the proximal phalanx considering the high recurrence of the tumour after curettage and bone grafting [243].

Intraoperative extracorporeal irradiation and frozen treatment on tumor-bearing autografts show equivalent outcomes for biologic reconstruction, with no differences in mean scores for graft fusion, resorption, fracture, shortening, and fixation [81]. Subchondral bone was graded with higher scores for the patients receiving frozen autografts compared to extracorporeal-irradiated autografts (p = 0.03) [81]. The incidence of atrophic nonunion was not significantly different between groups receiving irradiated (10%) or frozen (12%) autografts (p = 0.74) [81]. Most complications (87% in extracorporeal irradiation-treated group and 88% in frozen-treated group) occurred during the first 3 years after surgery for tumor-bearing autografts [81]. The complication rates were decreased to 11% in the extracorporeal irradiation group and 4% in the frozen-treated group by the end of the 5-year followup [81].

Of 104 intercalary allograft procedures, 51 (49%) led to an excellent result, 36 (35%) to a good result, 2 (2%) to a fair result, and 15 (14%) to a failure, resulting in a composite rate of good and excellent results of 84% [33]. Most failures of intercalary allografts occurred in the first three to four years, with the pattern in subsequent years generally being one of stability [33]. The stage of the lesion (p = 0.007), infection (p = 0.0001), fracture (p = 0.002), and the use of adjuvant chemotherapy or radiation, or both (p = 0.008), all had an adverse effect on the survival of intercalary allografts [33]. Age, gender, anatomical site, and length of the graft were not associated with significant differences in the overall outcome of intercalary allografts (p < 0.05) [33]. For eight of 100 patients with failed intercalary allografts, the most appropriate procedure was deemed to be an amputation [33]. Ninety-two patients, including those who had had removal of the graft, retained the limb after intercalary allograft procedures [33].

Pediatric and Congenital Conditions

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.

Complications

Wound complications: Firework-related hand injuries frequently necessitate reconstruction rather than simple repair, with many patients requiring secondary procedures [1]. Local flap reconstruction for digital soft tissue defects carries an acceptable risk of adverse events at 5.4%, with reoperations required in approximately 2% of cases [30]. In modified pivot flap reconstruction of fingertip defects, venous congestion was observed in two flaps; one case resolved spontaneously within 3 days, while the other developed superficial partial flap necrosis that healed conservatively in 10 days [219]. Refinements in the dorsoulnar flap of the thumb can help avoid donor site complications [225].

Recurrence and Deformity: 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 [7]. Five years after successful collagenase clostridium histolyticum treatment for Dupuytren contracture, the overall recurrence rate was 47%, a figure comparable with published recurrence rates after surgical treatments [54]. One long-term treatment-related adverse event was reported in the 5-year follow-up of this enzymatic therapy [54].

Reoperation and Revision: Approximately 13% of syndactyly reconstructions require reoperation, with most occurring within 4 years of the primary procedure [222]. 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 [66]. Reconstructive surgery was required in 15% of patients during the 10-year follow-up period after hand burns [73]. Longer follow-up and prospective randomized comparisons are needed to better define rates of revision, failure, and complications for proximal interphalangeal joint prosthetic arthroplasty [59].

Other Considerations: Combined reconstruction strategies for severe hand injuries demonstrate acceptable complication rates and good functional recovery [2]. Despite complications such as flap necrosis or loss, microsurgeons continue to push the limits of reconstructive and replantation feasibility in the upper extremity [49]. 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 [55]. Vascularised fibular grafts for reconstruction of extremity bone defects are associated with a relatively high rate of complications [65], with complication rates reported after free vascularized fibular graft reconstruction remaining high at 37%–80% and varying widely in frequency [211]. Arterial grafts in upper extremity vascular reconstruction have patency rates up to 100% reported in intermediate-term outcomes, though no long-term outcomes studies exist [69]. Limb salvage for extremity sarcomas has higher rates of postoperative complications, including infection, aseptic loosening, and graft or prosthetic failure, compared to amputation [156].

Recovery

General Principles and Timing: Early or immediate complete upper extremity reconstruction is the treatment of choice where possible, as it yields better results than delayed or late reconstruction [26]. This approach enables early hand therapy, earlier return to function, and improved outcomes compared to delayed reconstruction [10]. Furthermore, early microsurgical reconstruction following radical debridement significantly lowers postoperative morbidity, infection rates, and the number of subsequent procedures compared with delayed or late operations [254]. In post-traumatic upper limb reconstructive microsurgery, early aggressive debridement and immediate all-in-one reconstruction offer the best functional results [79].

Specific Surgical Techniques and Indications: 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 [8]. If these early surgery criteria are not met, it is better to wait until 2 to 3 months to refine the surgical plan [8]. Regarding Zone 2 flexor tendon injuries, the time elapsed between injury and surgery is not an important risk factor for a good outcome; instead, outcomes depend on proper surgical methods, the surgeon's experience, and early mobilization [83].

Long-Term Functional Outcomes: Recurrent or persistent deformity in Boutonniere finger deformity is best treated with a salvage procedure [7]. Long-term results after surgical reconstruction for radial polydactyly were excellent, although the revision rate trended upward over time despite maintenance of favorable scores on objective outcome measures [66]. Long-term outcomes of arthrodesis for severe recurrent proximal interphalangeal joint contractures in Dupuytren’s disease show high patient satisfaction and allow for fairly rapid return to function with no requirement for revision surgery [67]. Syndactyly reconstruction yields satisfactory subjective long-term outcomes [68]. The uniquely long-term follow-up of toe-to-hand transfer demonstrates that favourable long-term results can be achieved [164]. Follow-up assessments show that the majority of zone I replantations led to satisfactory function [165]. The results of bone–periosteum–bone graft reconstruction for chronic ulnar instability of the metacarpophalangeal joint of the thumb support the long-term durability of this method [166].

Other Considerations: Surgical correction for Keratoderma Hereditarium Mutilans (Vohwinkel Syndrome) is easy to achieve but difficult to maintain, resulting in poor long-term outcomes with a high rate of recurrence [168]. After 3D planning and patient specific instrumentation for intraarticular corrective osteotomy, ROM and grip strength improved postoperatively comparable to the healthy contralateral side, and patient-reported outcome measures improved after medium-term follow-up [171]. The procedure of 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 [55]. There appears to be no benefit to tendon interposition or ligament reconstruction in the longer term for trapeziometacarpal osteoarthritis [72]. Tendon transfers after peripheral nerve injuries provide predictable and consistent outcomes based on over 50 years of experience [255].

Specific Flap and Graft Outcomes: Combined reconstruction strategies for severe hand injuries using posterior interosseous artery flaps combined with local and regional flaps have acceptable complication rates and good functional recovery [2]. At long-term follow-up, patient-reported outcome measures and objective outcomes of the homodigital unipedicle neurovascular island flap for fingertip coverage are satisfactory, and the flap is considered safe and reliable [9]. The modified reverse flow shunt restricted arterialized venous free flap resulted in high flap survival rates with satisfactory functional outcomes in a clinical series of 9 cases [27]. A series of 79 free flaps using the ulnar artery distal cutaneous descending branch provided satisfactory reconstruction of hand wounds with 100% flap survival and acceptable aesthetic and functional results [50]. The cross-finger flap for reconstruction of fingertip amputations is a simple, reliable, long-lasting reconstruction technique [31]. 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 were followed up for 8–12 months with satisfactory appearance of the reconstructed thumbs [71]. 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, yet they have a high rate of successful limb salvage and a good long-term functional outcome [65]. Intermediate-term outcomes for arterial grafts in upper extremity vascular reconstruction are promising, with patency rates up to 100% reported [69].

Additional Surgical Considerations: There was no substantial clinical or radiological difference between radial shortening osteotomy and vascularized bone graft in long-term outcome for Kienböck disease [13]. 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 [253]. 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 [82].

Key Evidence

• [L4] Patients often require reconstruction rather than repair, and many will require secondary procedures, making prevention the best treatment. [1] (10.1016/j.jhsa.2014.08.041)
• [L4] Combined reconstruction strategies should be considered based on defect characteristics, with acceptable complication rates and good functional recovery. [2] (10.1016/j.injury.2026.113151)
• [L4] Reconstructive decision making is based on surgeon experience and popular consensus rather than excellent evidence. [3] (10.1016/j.hcl.2013.04.010)
• [L5] Current indications and methods, including delayed treatment and 1-stage and 2-stage reconstruction, are reviewed with future directions discussed. [4] (10.1016/j.jhsa.2007.08.018)
• [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. [5] (10.1016/j.jhsa.2016.04.020)
• [L4] Reconstructive surgery produced significant functional improvements at 6 months which remained essentially unchanged at the 4.5-year follow-up. [6] (10.1054/jhsb.1999.0265)
• [L5] Long-term results following soft tissue reconstruction are unreliable, and recurrent or persistent deformity is best treated with a salvage procedure. [7] (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. [8] (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. [9] (10.1177/17531934231172081)
• [L5] Early complete debridement and immediate reconstruction with free tissue transfer enable early hand therapy, earlier return to function, and improved outcomes compared to delayed reconstruction. [10] (10.1016/j.hcl.2014.01.001)
• [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. [11] (10.1177/1753193417723310)
• [L5] Essentially there are currently no criterion standard measures to evaluate the consequences of reconstructive arm/hand surgery. [12] (10.1016/j.apmr.2015.10.110)
• [L3] We were unable to recognize a substantial clinical or radiological difference between the 2 surgical treatments in long-term outcome. [13] (10.1016/j.jhsa.2012.11.016)
• [L5] Surgical intervention should follow the standard reconstructive ladder and can involve several techniques from simple to complex. [14] (10.1016/j.hcl.2016.12.006)
• [Paper] An algorithm based on anatomical considerations and functional outcomes can guide the plastic surgeon in dealing with complex situations. [17] (10.1007/s12593-011-0046-7)
• [L5] The functional importance of the hand is often underestimated but there has been an increasing recognition for this rapidly expanding and particularly challenging area of reconstructive surgery. [19] (10.1016/j.hcl.2014.07.007)
• [L5] They recommend replacing like with like, using pedicle perforator flaps for medium defects and free flaps for large defects to achieve optimal functional and aesthetic outcomes. [21] (10.1016/j.hcl.2017.04.001)
• [L4] Free flap reconstructions offer critical advantages over non-microsurgical techniques, including early mobilization and appropriate coverage with acceptable donor morbidity. [23] (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. [25] (10.5435/jaaos-d-18-00218)
• [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. [26] (10.1007/s00264-012-1638-y)
• [L4] In this clinical series of 9 cases, the modified technique resulted in high flap survival rates with satisfactory functional outcomes. [27] (10.1016/j.jhsa.2018.02.023)
• [L5] Compared with no reconstruction, any procedure is of benefit. [29] (10.1016/j.jhsa.2016.09.012)
• [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. [30] (10.1016/j.hcl.2019.08.009)
• [L4] This is a simple, reliable, long-lasting reconstruction technique. [31] (10.1016/j.otsr.2016.03.006)
• [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. [32] (10.1177/1753193418793579)
• [L3] [33] (10.2106/00004623-199701000-00010)
• [L2] [34] (10.1177/1753193417712879)
• [L5] The choice of reconstruction depends primarily on the amount of volar skin available, the patient's functional demands, and the surgeon's expertise. [40] (10.1016/j.hcl.2019.09.002)
• [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. [44] (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. [45] (10.1177/1753193411406479)
• [L5] Most patients are at least moderately satisfied with the improvement in function achieved by reconstructive surgery. [47] (10.1054/jhsb.2001.0730)
• [L4] [48] (10.1007/s11552-007-9081-z)
• [L5] Despite complications such as flap necrosis or loss, microsurgeons continue to push the limits of reconstructive and replantation feasibility. [49] (10.1016/j.hcl.2010.01.007)
• [L4] The series of 79 free flaps provided satisfactory reconstruction of hand wounds with 100% flap survival and acceptable aesthetic and functional results. [50] (10.1016/j.injury.2009.04.009)
• [L4] The method of soft-tissue reconstruction has no effect on functional outcome. [51] (10.1302/0301-620x.96b5.32241)
• [L4] It mimics normal anatomy with minimal disruption to local soft tissue structures and provides biomechanical advantages over previously described techniques. [53] (10.1016/j.jhsa.2012.12.021)
• [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. [54] (10.1016/j.jhsa.2015.04.036)
• [L4] The procedure is safe, with a low complication rate, and demonstrates long-term durability. [55] (10.1016/j.jhsa.2009.03.016)
• [L4] This procedure is mainly chosen by selected patients who refuse standard microsurgical thumb reconstruction because it requires a longer treatment period. [57] (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. [58] (10.1054/jhsb.2001.0595)
• [L4] Longer follow-up and prospective randomized comparisons are needed to better define rates of revision, failure, and complications. [59] (10.1016/j.jhsa.2010.04.005)
• [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. [60] (10.1177/17531934231220783)
• [L5] The need for refinement and secondary surgery should be taken into consideration during the initial flap selection process. [61] (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. [62] (10.1054/jhsb.2001.0584)
• [L4] The procedure is recommended only as a salvage procedure. [63] (10.1016/j.jhsa.2020.06.001)
• [Paper] The main advantages of propeller perforator flaps, i.e. no need of microvascular anastomoses, replacing like-with-like, faster functional rehabilitation, can reduce in well selected cases the indication for free flaps. [64] (10.1016/j.injury.2019.10.037)
• [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. [65] (10.1302/0301-620x.99b9.bjj-2017-0219.r1)
• [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. [66] (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. [67] (10.1177/1753193420960309)
• [L4] Syndactyly reconstruction yields satisfactory subjective long-term outcomes. [68] (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. [69] (10.1016/j.jhsa.2012.12.009)
• [L5] Vascular complications of flap procedures and replantation surgery in the upper extremity can be minimized by employing appropriate indications and thorough preoperative planning. [70] (10.1016/j.hcl.2015.01.008)
• [L4] All flaps survived and patients were followed up for 8–12 months with satisfactory appearance of the reconstructed thumbs. [71] (10.1177/17531934231222400)
• [L1] There appears to be no benefit to tendon interposition or ligament reconstruction in the longer term. [72] (10.1016/j.jhsa.2011.11.027)
• [L4] Reconstructive surgery was required in 15% of patients during the 10-year follow-up period after hand burns. [73] (10.1016/j.jhsa.2017.02.006)
• [L5] Effective management of thumb hypoplasia requires an understanding of the embryology, epidemiology, classification, presentation, and management options. [74] (10.5435/00124635-200606000-00005)
• [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. [79] (10.1177/1753193420915398)
• [L3] [81] (10.1007/s11999.0000000000000022)
• [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. [83] (10.1177/17531934211024435)
• [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. [87] (10.1302/0301-620x.96b11.34747)
• [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. [92] (10.1177/1753193421995697)
• [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. [117] (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. [119] (10.5435/00124635-199803000-00004)
• [L4] This flap provides adequate soft tissue and good functional outcome compared with other salvage procedures. [123] (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. [125] (10.1054/jhsb.1999.0199)
• [L2] The reconstruction using parallelogram flaps is a easier and more versatile treatment with better functions, less morbidity and better aesthetics. [126] (10.1186/s13018-022-03214-1)
• [L4] Flap survival was 100% and functional improvement with near normal appearance was obtained in the reconstructed thumbs. [134] (10.1054/jhsb.1998.0176)
• [L5] Advances in microsurgery have provided improved thin, pliable, durable flaps that offer cosmetic reconstructive options. [135] (10.1016/j.jhsa.2014.12.037)
• [L5] The outcome of the initial debridement, repair, soft tissue coverage, and hand therapy greatly influences the need for secondary procedures. [136] (10.1016/s0749-0712(02)00146-4)
• [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)
• [L5] Despite the advent of microsurgery and skin substitutes, pedicled abdominal flaps remain relevant for specific indications including patient/facility factors deterring microsurgery, absence of recipient vessels, prior surgical use of vessels, need to preserve major vessels, and large multi-surface wounds. [144] (10.1016/j.injury.2020.02.105)
• [L5] Continued enhancement in immune modulation, surgical indication, patient selection, and posttransplant care is expected to make VCA a major milestone in reconstructive surgery. [145] (10.1016/j.jhsa.2017.01.019)
• [L4] The uniquely long-term follow-up presented here demonstrates not only the short to medium-term usefulness of toe-to-hand transfer, but also that favourable long-term results can be achieved. [164] (10.1054/jhsb.2000.0422)
• [L4] Follow-up assessments show that the majority of zone I replantations led to satisfactory function. [165] (10.1016/j.jhsa.2008.05.005)
• [L4] The results of the current study support the long-term durability of this method. [166] (10.1016/j.jhsa.2008.10.005)
• [L4] Surgical correction is easy to achieve but difficult to maintain, resulting in poor long-term outcomes with a high rate of recurrence. [168] (10.1177/1753193408098901)
• [L4] ROM and grip strength improved postoperatively comparable to the healthy contralateral side and patient-reported outcome measures improved after medium-term follow-up. [171] (10.1186/s12891-022-05946-x)
• [L4] However, magnetic resonance imaging indicates that the donor site is resurfaced with fibrous tissue. [176] (10.1177/0363546507306465)
• [L4] [180] (10.1016/j.jhsa.2018.10.011)
• [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. [182] (10.1177/1753193420983213)
• [L3] The study notes that while non-randomised, the technique appears better without an increased rate of rupture but with a shorter rehabilitation period. [193] (10.1177/1753193408091570)
• [L5] [198] (10.1016/j.jhsa.2011.04.017)
• [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. [202] (10.1054/jhsb.1999.0225)
• [L4] [205] (10.1016/j.injury.2008.06.007)
• [L4] [206] (10.1177/1753193408098904)
• [L5] [214] (10.5435/00124635-201102000-00003)
• [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. [217] (10.1177/17531934241247743)
• [L4] [219] (10.1177/1753193420956320)
• [L4] Approximately 13% of syndactyly reconstructions require reoperation, with most occurring within 4 years of the primary procedure. [222] (10.1016/j.jhsa.2024.08.012)
• [L4] The refinements of this series can help to improve the use of this flap and avoid complications in the donor site. [225] (10.1016/j.jhsa.2010.05.016)
• [L4] No conclusive evidence exists in favor of an immediate versus a primary, early or delayed emergency reconstruction. [230] (10.1016/j.injury.2019.10.056)
• [L5] The widespread availability of skin substitutes and the advent of negative pressure wound therapy provide adjunctive and alternative options to traditional reconstructive techniques for treating soft tissue defects of the hand. [233] (10.1016/j.hcl.2012.08.010)
• [L5] Free flap soft tissue reconstruction should be selected early in the treatment algorithm if a better end result can be anticipated, as it allows for early coverage with composite reconstruction of all damaged or missing tissues and early mobilization to restore function. [234] (10.1016/j.hcl.2007.02.007)
• [Textbook] [236] (10.1007/978-3-642-22697-7_29)
• [L4] [240] (10.1016/j.injury.2013.01.025)
• [L4] En-bloc resection and reconstruction using a non-vascularized toe phalanx may be preferred as a surgical alternative considering the high recurrence of the tumour after curettage and bone grafting. [243] (10.1177/17531934231209183)
• [L4] A new technique of quantifying the radiographic divergence of the border rays of the cleft demonstrates improved alignment at long-term follow-up. [244] (10.1016/j.jhsa.2008.05.010)
• [L4] All parameters showed the greatest magnitude of improvement between preoperative measurements and 1 year of follow-up. [247] (10.2106/jbjs.19.00685)
• [L4] [249] (10.1177/1753193409348182)
• [L5] [250] (10.1016/j.hcl.2020.03.011)
• [L4] [251] (10.1177/1753193408101464)
• [L4] The duration of banking before thumb reconstruction should be no more than 2 weeks. [253] (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. [254] (10.1016/s0749-0712(02)00128-2)
• [L5] The author's preferred techniques provide predictable and consistent outcomes based on over 50 years of experience. [255] (10.1177/1753193419864838)

See Also

• Dupuytren's Disease
• Flexor tendon repair

References

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