Upper Limb Reconstruction Surgery

Also known as reconstruction of the upper extremity, upper limb reconstruction involves reconstructing and/or restoring function to the upper limbs whose structure is made up of the hands, wrists, forearms, elbows, arms and the shoulders.

The damage to the upper limbs may have been caused by aggregated trauma and injuries, disease (cancer), or infection, which may have led to loss of soft tissue, tendons, bone, ligaments or nerves.

The goal of the procedure is to salvage and preserve function to the limb in question in order to circumvent any form of amputation either partial or complete, and as result restore quality of life.

The reconstruction of the upper limb is performed by a team of multi-disciplinary experts who include an orthopedic surgeon, trauma surgeon, and a plastic and reconstructive surgeon. These three components work together to attain the best functional and aesthetic functions to the affected limb.

Conditions Treated with Upper Limb Reconstruction Surgery

Some of the conditions that may require an upper limb reconstruction procedure include:

• Cases where a fracture or broken bone fails to heal on its own, also known as fracture non-union
• Injury to the surrounding tissue on the limb, shearing or loss of muscle, fascia and Pericranium (outer surface of the bones)
• Bone infection (osteomyelitis)
• Tendon exposure
• Restriction of natural movement of a limb as a result of scar tissue, also known as scar contracture
• Chronic phantom pain after amputation or injury

Techniques Used in upper Limb Reconstruction

The reconstruction technique used on the upper extremity depends on the type of defect and the function of the extremity. Appropriate techniques on reconstruction are implemented for the bones, joints, muscle tissues(tendon) and nerves that are injured, although sometimes the need for amputation maybe be required.

Plastic reconstructive surgery is an important feature for management of upper extremity trauma. The plastic reconstructive surgeon is involved greatly in skin grafting, microvascular free flap transfer, local tissue arrangement, and salvaging the limb.

Some of the techniques used in upper limb reconstruction include:

Grafting/ Debridement

This is a surgical or non-surgical procedure of cleaning a wound by removing the unhealthy foreign materials and dead tissues. This is done to prevent infection, reduce scarring and enhance healing of the wound. Before reconstruction, it is necessary to consider debridement of the wound to identify what type of repair will be performed. Debridement of the wound is preferred in the first phase followed by the flap coverage in the second phase after 1-2 days of the procedure.

In a non-surgical procedure, the wound is cleaned by using water/medicine and syringes to remove the dead skin. Alternatively, a wet dressing is applied on the wound and left on until it dries then removed with the dead tissue.

For surgical procedure, tools are used to cut away the dead tissues on deep larger wounds. A patch of skin is removed from one part of the body and transferred to the wound, to promote healing.

Flaps

Flap coverage is the most common technique used in limb reconstruction. The technique entails free flaps, local flap, regional and distant flaps. Pedicled flaps are also essential flaps for the reconstruction of the upper limb as they have a better outcome in coverage and functional reconstruction.

Patients with acute trauma require flap coverage for the purpose of:

• Improving function of a patients’ condition that may have resulted from a previous injury or disease
• Reconstructing an implant exposed after an orthopedic procedure interference
• Resurfacing unsecured scars

Pedicled Flaps on Defects of the Arm and Elbow

Pedicled flap coverage is performed on an exposed neurovascular structure and where wounds are clean.

For Posterior, anterior, circumferential and composite soft tissue defects of the arm, pedicled flap that consist of latissimus dorsi myocutaneous flap (LDMF) is adaptable for this procedure. The adaptability is applicable to the donor sites’ morbidity, vascularized voluminous muscle and its large surface area. The flap is planted in the injury, staging a reconstruction that is followed by a neurovascular repair.

Lower arm defects that occur on the front and to the side (anteromedial) or near the dorsal midline of the body posteromedial), can be covered with thoracoabdominal flap (TAF). The flap produces fasciocuteneous tissues which are used for the coverage of the defects.

For coverage of the large soft tissues on the elbow, pedicled flap is used for the dorsal and ventral surface (which include the palm and shin). The radial and ulnar artery, which act as perforators of the arm, is used together with fasciocuteneous flap to cover medium sized soft tissues defects of the forearm.

Fasciocuteneous flap and muscle flaps

To eliminate dead space which might have been caused by an infection, it is simpler to use muscle flaps which need a skin graft. This promotes wound and bone healing and restores the function of the said body part. The muscle flaps used are Latissimus dorsi, serratus anterior and rectus abdominis flaps.

Fasciocuteneous flaps also provide an efficient coverage for tendons as they result in minimal scarring, and the hand restores its sensitivity when using the flap. The fasciocuteneous flap that is commonly used for reconstruction of the upper limb are lateral arm, scapular, forearm flap and temporospatal fascial free flap.

Free Flaps

Free flaps are the best option for a single stage procedure as they provide an efficient coverage for severe injury on the upper limbs, have healthy tissues which assist in growth of the vascular tissue, and enhance faster healing due to the blood supply. Free flaps are used to cover soft tissue infections and wounds left after a tumor excision.

Recovery process of the procedure done with free flaps commences 24 hours after the surgery when the muscles have not lost strength and function.

Perforator Flap

Perforator flaps usually have better aesthetic results because they match with the tissues, are reliable and able to rotate, and can be harvested away from the area of the defect. Perforator flaps can be harvested in thin vascularized and flexible skin flaps. The underlying muscle is conserved, and for small defects the donor site does not require a skin graft. These flaps are used for small defects of the upper limb reconstruction.

Salvage or Amputation

Amputation is considered when the damage is severely beyond possible reconstruction and life-threatening injury has occurred. Additionally, amputation is considered when there is severe partial traumatic anatomical, vascular, soft tissue defects and lack of infrastructure and resource to make the reconstruction possible.

Possible Risks That May Lead to Amputation

The Orthoplastic approach will escalate positive results, however, amputating the limb can be considered over salvaging. The risk of amputation can be brought on by factors such as:

• Severity of damaged muscle
• Laceration which could stop sensation on the limb even after reconstruction
• Degree of ischemia (lack of blood flow) and infection
• Accompanying medical conditions or injuries which may put the patient at risk

Postoperative Care

After the upper limb reconstructive surgery, the patient will have consecutive neurovascular checkup of the operated area on an hourly basis for the first 2 days of the surgery. Then after every 4 hours for the next 3 days.

If a splint was put in place, then it is removed after the 4^th day post-surgery. A physical therapist may be recommended. Medication to prevent clot formation and artery blockage is also prescribed.

Possible Complications of Upper Limb Reconstruction Surgery

Just like every other surgical procedure, upper limb reconstruction has risks that may occur such as:

• Bleeding
• Scarring
• Infection on the treated area
• A need for the surgery to be revised
• Complications from the anesthesia
• Partial or complete amputation of the limb in question

Pre-Op Guidelines

Depending on the severity of defect or damage to the upper limb, the reconstruction surgery is best performed by a qualified and experienced plastic and reconstructive surgeon and Orthopedic surgeon. A detailed consultation with the experts in question is highly recommended, which can happen multiple times before the reconstructive procedure takes place. During the consultations, the reconstructive surgeon will evaluate the patient, discuss on what the patient aims to achieve, the different techniques and approaches, the benefits of the procedure, the risks involved, the outcome and finally the recommended approach for optimal results and recovery.

Post-Op Guidelines and Recovery

For safe, faster, and optimal recovery after upper limb reconstructive surgery, the patient should follow all the recommendations made by the reconstructive and orthopedic surgeons, from taking care of the wound, prescribed medications, follow up on the doctors’ appointments, the dos and don’ts, and what to watch out for in cases of emergencies.

Get in Touch

Reconstructive surgery at Kings College Hospital Dubai focuses on the safety and care of every patient in a compassionate environment with state-of-the-art facilities. To book an online or in-person consultation and a detailed evaluation by one of our world class plastic and reconstructive surgeons in Dubai, get in touch using the contact details given, and our patient-care staff will book an appointment for you.