Evaluation of long-term clinical outcomes of innervated digital artery perforator flap

Fingertip amputations and tissue loss after fingertip injury are frequently encountered in daily practice of hand surgery. Fingertip injuries can lead to serious functional and aesthetic loss in the hand. In addition to causing problems in patient's work and daily life, fingertip injuries also affect patients psychologically. The goal of the treatment of fingertip injuries is to restore an esthetically pleasing and painless fingertip that can sense pain, temperature, pressure, stereognosis, and proprioception. Several methods have been developed in the treatment of fingertip injuries with tissue loss: dressing changes, shortening, grafting, local, regional and free flaps, replantation etc. However, all of these techniques have specific advantages and disadvantages. Therefore, the most appropriate treatment should be chosen considering the type of the injury, time since the injury, expectations of the patients in work and daily life, experience and skill of the surgeon. In 2006, Koshima et al reported a new entity called digital artery perforator flap (DAP) in the treatment of fingertip injuries with tissue loss. In 2013, Özcanlı et al reported the innervated digital artery perforator flap (IDAP). In the present study, long-term clinical outcomes of the patients who underwent reconstruction with IDAP flap in the treatment of fingertip tissue loss, were evaluated. 83 patients (93 fingers) who were regularly followed up before and after surgery and whose physical examinations and measurements were regularly recorded and followed longer than 1 year, in Akdeniz University, Faculty of Medicine, Department of Orthopaedics and Traumatology between August 2011 – October 2016 were included in the study. Acute or late reconstructions were performed to the fingertip injuries with the use of IDAP flap. Mean age of the patients was 35.2 years (range 5-65 years). Objective and subjective evaluations were performed in the postoperative controls. Statistical two-point discrimination (s2PD) and Semmes-Weinstein monofilament (SWM) tests were performed as objective parameters in comparison with the tips of the same fingers in the patient's intact hand. Range of motions of the reconstructed fingers were evaluated. Conditions that affect regional blood flow negatively (diabetes mellitus, vasospastic problems, smoking etc.) were questioned. Hypersensitivity, cold intolerance and patient satisfaction were questioned as subjective evaluation parameters. The mean follow-up period was 33.1 months (range 12-60 months). The static 2-point discrimination measured on the flaps ranged from 2 mm to 6 mm (mean 3.7 mm); compared with 2 mm to 5 mm (mean 2.7 mm) on the contralateral fingers. Semmes-Weinstein test results ranged from 2.44 to 4.31 on the contralateral fingers, compared with 2.44 to 4.56 on reconstructed fingers. No partial or total flap loss was observed in any of the patients. None of the patients suffered from postoperative infections. There was no donor site morbidity. Superficial epidermolysis was observed in 4 fingers (4.3%). However, no second surgical procedure was applied to any patient. Ninety out of 93 fingers (96.8%) reconstructed with IDAP flap showed no limitation of motion in any joint. Only 4.3% of the 93 fingers (4 fingers) had hyperesthesia. Mild cold intolerance was observed in 18 fingers (19.3%). Mild hyperpigmentation was detected in 2 fingers (2.15%). When evaluating both functional and aesthetic conditions of the patient, 75 patients (90.3%) reported being "very good" and 8 patients (9.7%) reported being "good". In conclusion, the innervated digital artery perforator flap is a quick, sensory, reliable and versatile flap with excellent functional and aesthetic results, which can be used for early and late reconstructions of all types of fingertip defects.