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Reconstruction of a palmar infection related tissue defect with heterodigital island flap in a diabetic patient: A case report Enhancement of Palmar Advancement Flap: A Simple Modification

Hand infections are particularly important in diabetic patients, because of the rapid progression and high risk of morbidity. Infections should be treated emergently with sufficient debridement and appropriate antibiotics. Comorbid situations, type of infection and late intervention are important predisposing factors to complications such as tissue necrosis. Tissue defects should be reconstructed with a similar tissue that does not cause movement restrictions or contractures that have adequate thickness. In this study, heterodigital island flap in reconstruction of a palmar defect caused by infection in a diabetic patient is presented. ABSTRACT Background: Distal fingertip amputations with exposed bone is challenging for the surgeon to manage. In order to re-construct a good sensate pulp with appropriate closure, various flaps are advocated in the literature. Of these, palmar advancement flap, first described by Moberg in 1964, comprises one of the most popular options. Methods: Thirteen patients (11 male, 3 female) with fingertip injuries were operated. Following the elevation of Moberg flap, proposed modifications were carried out. Joint mobility and pulp sensitivity were recorded as well and advancement scores were noted before and after the modification. These scores were assessed statistically. Results: No complications were noted and there was no need for additional surgery. Excellent joint mobility and pulp sensitivity were maintained. This modification showed a statistically significant improvement in the advancement (p<0.05). Conclusions: Moberg flap is a good option for the closure of fingertip defects. Some simple modifications, as described in here, can enhance the advancement while securing the entire advantages of the flap.


Introduction
Soft tissue infections of the hand have been important factors for morbidity and mortality in diabetic patients [1]. Vascular insufficiency, immune deficiency and predisposition to trauma have been the major problems causing acute soft tissue infections of the hand. Infections in these patients have a tendency to spread wide areas via anatomical spaces. Additionally; skin necrosis could be seen according to infectious agents [2,3]. For this reason early surgical debridement has been the most important factor in preventing the spread of infection. After the acute phase of the infection, the resulting defect should be reconstructed with a reliable and functional method that is chosen taking into consideration the location and depth of the defect [4].
The heterodigital island flap for reconstruction of a hand defect after infection in a diabetic patient is presented in this study.

Case Report
A 55 years old woman referred to our clinic with erythema, edema and pain in the hand. She was diabetic for approximately 10 years but she was not taking any medication. Her complaints began after an injury with a thorn of a plant. Two days after the beginning of the complaints she went to a primary health care center and oral antibiotic treatment with Amoxicillin-Clavulanic acid was administered. Erythema and edema in the left hand and infectious necrotic tissue from second web space to the third finger were seen in physical examination ( Figure 1). There was pain with passive motion of the fingers. Hypoesthesia on all fingers was noted.
No other systemic comorbidities except diabetes mellitus were detected. Urgent surgical debridement of the necrotic tissues was planned. Necrotic tissues over the second web space through third finger debrided under wrist bloc anesthesia. Midpalmar space was drained

Introduction
The hand is a unique part in the body in and plays important and often irreplaceable functions. In the industrialized world, occupational hand injuries need to be healed as soon as possible. Meanwhile, several healing techniques with various options are being applied to hundreds of thousands of patients by experienced practitioners.
Unlike other hand injuries, fingertip amputations need additional attention in order to establish a normal pulp sensibility and maximum range of motion, and like others to maintain the upmost level of hand functioning.
In 1964, the volar advancement flap was first described by Moberg for the reconstruction of pulp defects of the thumb (1). This flap is a pedicled advance-ment flap proximally based on an intact skin pedicle including both neurovascular bundles. This technique establishes a successful neurosensation of the pulp with a limited advancement as well. However, a simple modification as described here, and never been reported elsewhere, can enhance additional advancement.

Patients and Methods
The study was performed with informed consents obtained from all participants.
Technique Thirteen patients (11 males, 3 females) with fingertip injuries were operated under regional anaesthesia. Palmar advancement flap was raised over the parathenon (1) (Figure 1a). Both neurovascular bundles were included in the flap so that neurosensible coverage is accomplished (Figure 1b). To increase the and irrigated with saline. Fasciotomies to the second and third fingers and dorsum of the hand were made to decrease the compartmental pressures. Vancomycin resistant enterococcus was the cultured agent from the wound cultures. Intravenous antibiotics (Piperacillin-Tazobactam 3,5gr/day) were administrated. The edema and erythema regressed gradually after the operation.
Wound dressings with antibiotic pomades were made on a daily basis. A 3x2 cm defect on the proximal phalanx of the third finger and the distal part of the palm with flexor tendon exposition was found. Reconstruction with heterodigital island flap from the radial side of the fourth finger proximal phalanx was planned. Bilateral digital arteries of the fourth finger were checked for patency with Allen test and Doppler ultrasonography. The heterodigital island flap from the radial side of the fourth finger was elevated under infiltration anesthesia. The vascular pedicle was dissected until the bifurcation and the flap was inserted to the defect on the third finger. Defects on the palmar area were primarily repaired. A full thickness skin graft taken from the inner arm re-   gion was put on the donor area ( Figure 2). There was minimal contracture on the second web space in the postoperative 8th month (Figure 3). Motor functions were found to be in the normal range. Postoperative evaluation of sensation in the fingertips remained the same as in the preoperative state, except for a decrease in the radial part of the fourth finger.

Discussion
Diabetes mellitus could make predisposition to infections by effecting cellular immune mechanisms especially in patients without normoglycemic control. Cellular immune deficiency and microangiopathic changes have an impact on developing infections in the areas that are prone to trauma [5,6]. The hand is a potential source of infection for diabetic patients with frequent traumatic injuries and the presence of anatomical spaces can result in rapid progression of these infections [2]. These infections could lead to defects that need to be reconstructed with carefully chosen methods. There are many reconstructive methods including skin grafts, local and regional flaps. Discussing the importance of the heterodigital flap as a reconstructive option was aimed in this study. Reconstruction of the defect should be made after the acute phase of the infection. Although some authors have revealed no increase in the incidence of hand infections in diabetic patients; Houshian et al. has observed a six times increase in the diabetic patients [1,7]. In the study of Yacoubi et al. an increase in E. coli growth in wound cultures in diabetic patients was observed [8]. Mixed flora composed of gram positive, gram negative bacterial and fungal agents were isolated in 52% of patients in the same study. It is remarkable that none of 111 patients in the study by Yacoubi et al. was presented with Vancomycin resistant enterococcus infection.
Early surgical intervention is crucial for hand infections in diabetic patients. The infection with the potential of rapid spreading between anatomical spaces can be regressed with appropriate debridement. The amputation ratio of one or more fingers in diabetic patients with hand infections is around 14% -35% [6,9]. In today's clinical practice salvaging the finger should be the main purpose of treatment. Even with prompt intervention and treatment morbidities such as tissue defects can occur. In these circumstances, reconstruction should be made regarding the location and the size of the defect after total elimination of the infection. Skin grafts, local, regional or free flaps are the options for reconstruction of hand defects. Exposition of the vital tissues should also be considered when the decision for reconstruction is made. Reconstructive algorithms for defects of specific areas in hand are well described [4,10]. The defects related with infections can be located on multiple atypical regions thus requiring specific reconstructive plans. The infection at the palmar region and third finger resulted in a defect on volar side of third finger through second web space and distal palm with exposition of the flexor tendons and the neurovascular bundles in the presented case. Our choice was to close the defect with pliable and durable tissue, which could allow free tendon movement and also cover the exposed neurovascular bundles. The skin grafts were not suitable because of the exposed structures. Local flaps that could be planned around the defect were not suitable because of possible infection. Distant flaps like abdominal interpolation flaps were not chosen as firstline reconstructive option because they involve two stage operations.
The heterodigital island flap from the radial part of the fourth finger was first described by Littler in 1953 for thumb defects. Later it was used for other parts of the hand since it provided sensorial tissue for reconstruction [11][12][13][14][15]. The main disadvantage of this flap is the sacrifice of the neurovascular bundle of the digit in one side. Checking the patency of both digital arteries with Allen test and Doppler ultrasonography has vital importance. Improvement of the sensibility in the recipient finger could be an advantage for patients. However, in patients in whom the loss of sensibility cannot be tolerated, as in sophisticated workers, the morbidity at donor finger should be kept in mind. In our case the patient had decreased sensation in all fingers, which caused her not to realize the thorn in her hand in the early trauma period. Even though the sensation of radial side of the 4th finger was sacrificed, no remarkable decrease in the sensation was noted and a successful closure of the important anatomical structures in the 3rd finger was also achieved. To conclude, hand infections can cause skin necrosis in large areas by rapid spreading in diabetic patients. The reconstructive option for the atypical defect should be chosen individually for every patient. Heterodigital island flap can be a reliable reconstructive option in these cases.