Reconstruction of the first web space post cicatricial contracture: Which technique to use?

Background

The first web space not only plays an integral role in hand functionality, but also holds an important aesthetic function for patients with cicatricial contractures, which hinders the ability to move joints, thereby restricting the performance of everyday activities. Therefore, a wide variety of reconstruction options are available. In this study, our main aim was to have a clear surgical plan prior to surgery according to preoperative findings and the degree of thumb abduction span.

Methods

This study was conducted at Kasr Al-Ainy Hospital. This cohort study included 33 patients with cicatricial first web space contractures who underwent reconstructive procedures to restore the first web space. Patients were assessed preoperatively and categorized according to the degree of contracture, and the reconstruction procedure was chosen accordingly. They were assessed using both objective and subjective methods.

Results

In this study, 33 cases of cicatricial contracture of the first web space due to physical or thermal trauma were included. Measurements of the change in the span of abduction were performed for all patients included in the study preoperatively and postoperatively. Skin grafting and skin substitutes had an average change in abduction span of 32.5° (± 14.4°), Z-plasty release had a mean of 30.59° (± 8.82°) increase in abduction span, regional flaps had an increase of 40.71° (± 12.39°), while distant flaps had an increase of 35° (± 3.54°).

Conclusion

No single reconstruction method can be used in all cases. When viewing a patient, one must consider that each individual has a unique representation. However, if we follow a systematic method for the initial evaluation, the most efficient flap can be chosen for each case, thus reducing the need for secondary procedures. Categorizing the cases according to the abduction span into mild, moderate, or severe forms is the first building block of this algorithm. Adjacent tissue condition, patient occupation, compliance, and the need to return to work are important factors.