Thumb Reconstruction by
Microvascular Methods
Dr Suiyibangbe
M.Ch Plastic and Reconstructive Surgery

Introduction
The thumb plays a crucial role in proper
functioning of the hand.
It is unimportant to humans only during the first
3 months of life.
At only 9 months of age, the thumb begins to
function as it will in adulthood.
Thumb opposition, unique to primates, allows
the human hand to perform power grip and
precision handling.
In fact, the thumb itself is responsible for 40% to
50% of the overall function of the hand.

Cont...
Reconstruction of the thumb remains a major
surgical challenge because of its unique
"position" in the hand's structure.
To provide a painless thumb with good stability,
sensibility, and mobility to oppose the adjacent
fingers.
The first priority is pain follow by stability, and
only then are sensibility and mobility considered.
Stability concerns both the skeleton and the skin
cover; the necessity of a distal vascularized bone
for avoidance of any long term resorption.

Cont...
• Microsurgical toe transfer is an excellent option for thumb
reconstruction because it meets all of the requirements for
providing good hand function.
• The toe, after all, is a digit itself and therefore is similar
anatomically to the thumb.
• Its skeletal structure consists of two phalanges motored by
extensor and flexor tendons.
• It is covered with durable glabrous skin that is innervated
by digital nerves.
• It provides all of the necessary components of good thumb
function and excellent appearance of the reconstructed
thumb.
• With proper operative planning and meticulous technique,
donor site morbidity and functional compromise can be
minimized.

• Figure 173-1 Key functional movements of the thumb: A, opposition; B, three-point
pinch; C, key pinch; D, cylinder grasp.

History
• In 1960, Jacobson and Suarez catapulted reconstructive
surgery to a new level with their report on anastomosis of
small blood vessels, giving birth to the era of modern
microsurgery.
• Subsequently, Buncke successfully performed toe to thumb
transfer on a rhesus monkey, proving the feasibility of this
procedure in primates.
• Toe to thumb transplantation was first reported in 1891 by
Nicolandi using a pedicled technique.
• In 1969, Cobbett performed the first microsurgical thumb
reconstruction in humans with a transferred great toe.
• Subsequent refinements in toe to thumb transfer and in
microsurgical technique have provided the hand surgeon
with an invaluable tool to restore hand function.

CAMPBELL-REID CLASSIFICATION FOR THUMB
AMPUTATION
Group 1:- Amputation distal to the
metacarpophalangeal joint, leaving an adequate
stump.
Group 2:- Amputation of the thumb distal to or
through the metacarpophalangeal joint, leaving a
stump of inadequate length.
Group 3:- Amputation through the metacarpal,
with preservation of some functioning thenar
muscles.
Group 4:- Amputation at or near the
carpometacarpal joint.

• Figure 173-11 Anatomy of the dorsalis pedis artery and its distal branches
to the great toe. (From Serafin D: Atlas of Microsurgical Composite Tissue
Transplantation. Philadelphia, WB Saunders, 1996:91.)

• Figure 173-12 A and B, Anatomic variations and their rates of occurrence in the dorsalis pedis artery
and its distal branches. DCA, distal communicating artery; DDA, dorsal digital artery; DPA, dorsalis
pedis artery; FDMA, first dorsal metatarsal artery; FPMA, first plantar metatarsal artery; PDA,
plantar digital artery; TML, transverse metatarsal ligament. (From May JW, Chait LA, Cohen BE, et al:
Free neurovascular flap from the first web of the foot in hand reconstruction. J Hand Surg [Br]
1977;2: 389. Reproduced with permission from The British Society for Surgery of the Hand.)

• Figure 173-25 Schematic representation of tissue that can be harvested in part or
in total for partial toe flap reconstruction. (From Serafin D: Atlas of Microsurgical
Composite Tissue Transplantation. Philadelphia, WB Saunders, 1996:142.)

THE PROBLEM
• The evolution of modern society has brought
with it new challenges for the hand surgeon.
• As the world's population continues to grow at
alarming rates, and as medicine finds new ways
to allow newborns with severe birth defects to
survive, the number and scope of congenital and
acquired non traumatic thumb anomalies have
increased.
• Progressive industrialization throughout the
world has increased the number of traumatic
hand injuries.

Causes of Thumb Loss
A. Congenital (partial or total) absence.
 Dietary deficiency
 Fetal neurogenic injury.
 Maternal viral infection, drugs (thalidomide )
 Reduced oxygen tension
B. Loss due to malignant disease, such as
melanoma.
C. Loss due to trauma. including industrial,
nonindustrial, and environmental insults.

Implications
• The degree of functional compromise associated with
thumb loss depends on the level of amputation.
• Thumb loss can be described as total or subtotal.
• In cases of total thumb loss, little or no metacarpal
remains; in subtotal loss, some amount of skeletal length of
the thumb is preserved.
• Subtotal loss has been further categorized.
1. Morrison subdivides subtotal loss into proximal subtotal
and distal subtotal loss, depending on the relationship of
the amputation level to the MCP joint of the thumb.
2. Strickland and Kleinman use a scheme that divides
subtotal loss into thirds (proximal, middle, and distal).
3. Amputation levels have been divided by Leung into four
"types“ that he thinks are useful for decision-making in
second-toe transfer.

Level of Amputation
From Morrison W, O'Brien BM, MacLeod AM:
Experience with thumb reconstruction. Br J
Hand Surg 1984;9:224.)
A, Amputation level as classified by
Kleinman and Strickland. B, This
classification can be useful in choosing
reconstructive options after thumb loss

• Figure 173-4 Schematic depiction of four types of thumb loss. (From Leung
P: Thumb reconstruction using second-toe transfer. Hand Clin 1985;1:286.)

ANALYSIS OF THE PATIENT WITH THUMB LOSS
• In the evaluation of patients being considered for
microvascular reconstruction of the thumb,
• History, physical examination:- toe transfer must
pay particular attention to the affected thumb or
recipient site of the operation, assessment of the
length, mobility, gross sensibility, vascularity, and
soft tissue coverage.
• Tests of hand function and anatomy to ensure for
a well-planned reconstruction.
• Plain radiographs demonstrate the skeletal extent
of the thumb's deficiency.

Cont...
• Vascular anatomy of the lower extremity must also be
assessed preoperatively. In addition to physical
examination, duplex ultrasonography or angiography
can be helpful.
• Planning of a proper thumb reconstruction also
requires assessment of preoperative hand function to
determine what functional needs the transferred toe
has to supply.
• Thumb range of motion including flexion, extension,
opposition, and both palmar and radial abduction and
adduction must be assessed.
• Sensibility can be assessed by subjective measurement
of light touch and two-point discrimination and by
Semmes-Weinstein monofilament testing.

Preoperative Consultation
• The surgeon must carefully assess the patient in
consultation to determine whether the patient is
an appropriate candidate for microvascular
thumb reconstruction.
• The procedure places significant physical
demands on the patient and requires intensive
postoperative rehabilitation.
• Stop smoking and tobacco free for at least 1
month before toe transfer. For confirmation of
abstinence from tobacco use, a urine nicotine
level can be checked within 24 hours of surgery. If
the result is positive, surgery is postponed until
the patient is able to cease use of tobacco
products.

TREATMENT
Goals
• In designing the proper treatment for thumb
reconstruction, the needs of the patient are a primary
consideration. patient's occupation, hand dominance,
and overall health are important.
• Microvascular thumb reconstruction places significant
physiologic, psychological, and socioeconomic
demands on the patient.
• A patient undergoing this procedure must be able to
modify daily activities to allow the tissues time to heal.
• Patients who are unable or unwilling to comply with
intensive hand therapy should not be considered for
toe to hand transfer because this procedure cannot
succeed without proper postoperative treatment.

Great-Toe to Thumb Transfer
• The great toe has historically
been the workhorse donor for
microsurgical toe to thumb
transfer.
• The great toe can be used in
its entirety, or it can be used
partially as either a
wraparound flap or trimmed
flap.
• The maximum circumference
of the contralateral thumb is
also measured, usually just
distal to the IP joint.
• This number is compared with
the maximum diameter of the
great toe.

Cont...
• Toe to thumb transfer is performed under general
anesthesia.
• The anesthesiologist must diligently maintain the
patient's body temperature to minimize
vasoconstriction.
• The patient's blood pressure should be maintained at
an adequate level to maintain perfusion to the toe flap.
• In general, a systolic pressure of at least 110 mm Hg is
desirable.
• Blood pressure should be managed with intravenous
fluid when possible, and vasoconstrictive agents should
be avoided.
• Dissection of both the hand and foot is done under
tourniquet control and loupe magnification.

Cont...
• Ideally, two separate surgical teams operate
simultaneously to minimize operative time.
• The goals of the hand dissection include careful
incision planning; identification of the anatomy of
the recipient hand; and preparation of the
skeletal, vascular, and neural structures of the
recipient hand for toe transfer.
• In general, an incision that designs proximally
based radial and ulnar flaps is preferred.
• The position of the radial artery should be
identified by palpation or Doppler examination
and then marked on the skin. It provides proper
orientation of incision

• Figure 173-7 A and B, Representative incision markings on recipient hands.

Cont...
• After elevation of the skin flaps, the digital nerves are
identified and dissected free from surrounding soft tissues.
• Nerve ends are then tagged with 8-0 nylon suture for later
identification.
• Tendons are next addressed if a dynamic toe transfer is
planned (static toe transfers, such as the wraparound
procedure, do not require tendon repairs).
• Next, the donor arterial supply must be addressed. The
artery is located by extending the dorsal incision proximally
toward the anatomic snuffbox, over the dorsal web space
of the thumb.
• Once it is identified, the artery is dissected free from
surrounding soft tissues and marked with a vessel loop.
• When an adequate vein is identified, it is dissected in a
fashion similar to dissection of the artery and marked with
a vessel loop for later identification.

Cont..
• If the toe is to be attached to the proximal phalanx of the
thumb or to the thumb metacarpal, the recipient structure will
have to be prepared for osteosynthesis.
• Once it is identified, the distal end of the bone is dissected
subperiosteally. An osteotomy is then performed with an
oscillating saw.
• If the toe is to be transferred to the proximal phalanx of the
recipient thumb, the osteotomy is made in a straight
transverse fashion.
• If the recipient bone is the thumb metacarpal, however, it is
preferred to make the metatarsal osteotomy with a slight
angle in a proximal dorsal to distal plantar direction.
• At the completion of the hand dissection, the tourniquet is
deflated to allow reperfusion of the upper extremity, and
hemostasis is achieved. The wounds are then dressed with
saline-moistened dressings until the donor toe is ready for
transfer.

• Figure 173-8 Completed dissection of the recipient hand. Tendons,
vessels, and nerves are tagged for easy identification.

TOE DISSECTION
• Toe dissection is ideally carried out by a second operative
team simultaneously with the hand dissection.
• The course of the dorsalis pedis artery and dorsal
superficial veins of the foot is marked out on the dorsal skin
of the foot preoperatively by a combination of palpation
and Doppler examination.
• Assessment of venous anatomy can be assisted by
dependent positioning of the extremity and the use of a
"venous tourniquet" with a tourniquet pressure of
approximately 80 mmHg.
• The incision for the toe harvest is also designed.
• In general, an incision that develops dorsal and plantar
flaps, with a dorsal proximal extension for vessel dissection,
is used. This provides good access for dissection and
develops flaps that are complementary to the radial and
ulnar flaps of the hand.

• Figure 173-9 Incisional markings for great-toe harvest.

Cont...
• After gravity exsanguination of the lower extremity and
inflation of the tourniquet, incisions are made.
• Dissection is performed with the assistance of loupe
magnification.
• Skin flaps are elevated laterally and medially on the
dorsum of the foot to expose the underlying
structures. Where it is possible, small sensory nerves
are preserved.
• Next, the superficial saphenous venous system is
examined, and one or more veins of adequate size and
length are identified as the donor vein.

• Figure 173-10 A and B, Intraoperative and schematic representations of great-toe dissection
showing the saphenous vein. (From May JW, Chait LA, Cohen BE, et al: Free neurovascular flap from
the first web of the foot in hand reconstruction. J Hand Surg [Br] 1977;2:391. Reproduced with
permission from The British Society for Surgery of the Hand.)

Cont...
• Next, the dorsalis pedis artery is identified proximally
in the dissection. This structure is dissected proximally
to provide adequate length for anastomosis to the
recipient artery in the hand.
• During this dissection, the extensor hallucis brevis
muscle is divided to allow adequate exposure of the
vessel
• The final structure on the dorsum of the foot that must
be prepared is the extensor hallucis longus tendon and
flexor pollicis longus tendon in the hand.

Cont...
• In great-toe transfers, the branch to the second toe is
divided just distal to the branch point of the first dorsal
metatarsal artery.
• Once the arterial and venous systems have been dissected,
they can be tagged with vessel loops for later identification.
• When re-establishment of dorsal sensory function of the
transferred toe is desired, the deep peroneal nerve, which
runs adjacent to the dorsalis pedis artery, can be included
in the flap.
• With the neurovascular and tendinous dissections
completed, attention is now turned to the skeletal support
of the toe.
• The osteotomy is performed with an oscillating saw.

• Figure 173-13 Pattern for metatarsal osteotomy of the donor toe. This permits osteosynthesis to
the proximal metacarpal in 60 degrees of extension, which transforms a primary extensor joint into
a flexor joint. (From Serafin D: Atlas of Microsurgical Composite Tissue Transplantation.
Philadelphia, WB Saunders, 1996:600.)

Cont...
• With the toe dissection completed, the lower
extremity tourniquet is deflated, allowing
reperfusion of the toe.
• Because of arterial spasm resulting from
dissection, the donor toe might remain pale for
up to 20 to 30 minutes after release of the
tourniquet.
• Spasm can be minimized by topical application of
compounds such as papaverine or concentrated
lidocaine (20%) to the vessels.
• Once reperfusion to the donor toe is established,
it should be allowed to perfuse for approximately
20 minutes before completion of the harvest and
transfer to the hand.

Great Toe transfer
• Figure 173-14 Explanted great toe before
transfer. EHB, extensor hallucis brevis; EHL,
extensor hallucis longus; FHL, flexor hallucis
longus. (Courtesy of Neil Ford Jones, MD.)
• Figure 173-15 Schematic of method of pin
fixation of the MCP joint after toe transfer.
(From May JW, Bartlett SP: Great toe-to-hand
free tissue transfer for thumb reconstruction.
Hand Clin 1985;1:274.)

Cont...
• With the recipient site prepared and the toe dissected,
transfer of the toe to the hand is next undertaken.
• The donor artery and then the vein are divided
proximally and flushed with lactated Ringer solution
containing 10 units/mL of heparin.
• The transfer is begun with reconstruction of the
skeletal framework.
• The joint should be pinned in a position of slight
flexion.
• Many techniques exist for osteosynthesis, including the
use of K-wires, rigid fixation systems, and interosseous
wiring.
• It is preferable to use rigid plate and screw fixation for
osteosynthesis because of its strength and allowance of
early active range of motion in the reconstructed
thumb.

• Figure 173-16 The transferred toe after vascular clamp removal. Note the healthy
color of the flap.

Cont...
• With the skeletal reconstruction complete,
repair of soft tissues is undertaken. It is
preferable to repair tendinous structures first,
then the nerves, followed by the artery and
finally the vein.
• If there is any question about the patency of
any of the vascular anastomoses revision
should be performed immediately.
• The microsurgical axiom "if you think it is
probably OK, it isn't" applies in this as in all
other microsurgical settings.

Cont...
• Donor and recipient skin flaps are brought into
approximation and trimmed as necessary.
• It is preferable to use a single-layer, tension-free closure
with interrupted monofilament suture.
• In children, absorbable suture, such as chromic gut, should
be used to eliminate the need for later suture removal.
• In situations in which flaps cannot be closed without undue
tension, a skin graft is used for cover, provided that all vital
structures, such as nerves, blood vessels, and tendons, are
covered by healthy vascularized soft tissue.
• After placement of the usual sterile dressings, the
extremity is placed into a well-padded thumb spica splint
with the tip of the toe flap visible for postoperative
monitoring.

• Figure 173-17 The wounds have been closed. Skin grafts are used
where needed to avoid undue tension in the closure.

Wraparound Flap
• Because the great toe is larger than the normal thumb,
various modifications of great-toe transfer for thumb
reconstruction have been developed to design a better
size match.
• The wraparound technique was first described by
Morrison et al in 1980.
• In this procedure, only the soft tissue and nail of the
great toe are transferred to the hand, without the
metatarsal or proximal phalanx of the great toe.
• An iliac crest bone graft, if required, provides skeletal
support for the reconstructed thumb.
• Indicated when complete skin avulsion in which the
skeleton and tendons remain intact reconstruction of
amputations distal to the MCP joint

Cont...
 The advantages of this flap
include
– better size match with the
opposite normal thumb;
– provision of sensibility,
– length, and stability to the
reconstructed thumb; and
– preservation of a portion of the
great Toe.
 The disadvantages to this flap.
– Because this is an essentially
static transfer when the use of
an iliac crest bone graft is
required, it is useful only for
thumb loss distal to the MCP
joint.
– If it were used more proximally,
the limitation of motion in the
thumb would be unacceptable.
– Another disadvantage of this
flap is its lack of potential for
growth because of the absence
of an epiphysis.
– Resorption of the bone graft is
another potential problem.

FLAP DISSECTION
• Because the ulnar vessels of the thumb tend to be dominant, the ipsilateral great
toe is usually chosen for wraparound great-toe transfer.
• The arterial supply to the flap tends to run in a medial direction as it courses
distally on the foot, which corresponds to the course of the radial artery in the
hand.
• Careful incisional planning is required for successful wraparound toe transfer.
• The circumference of the contralateral normal thumb must be measured at its
base and at the widest portion of the thumb pulp between the tip of the digit and
the IP joint.
• The donor toe is measured in a similar fashion and the difference between
corresponding measurements in the toe and thumb is determined.
• Markings are made to design a flap that is based proximally and employs the skin
of the dorsal, lateral, and plantar skin of the great toe.
• At the completion of the dissection, a tongue of proximally based skin and
subcutaneous tissue remains on the medial side of the great toe and is used for
closure of the donor site. The width of this tongue corresponds to the difference
between the circumference of the great toe and the circumference of the thumb
as measured.

• Figure 173-19 Incision markings on the foot for wraparound great-
toe transfer. (Courtesy of Neil Jones, MD.)

DONOR SITE CLOSURE
• A number of techniques have been described for
closure of the donor site after wraparound great-
toe transfer.
• The whole of the remaining skeletal framework
can be preserved and the soft tissues
reconstructed by a combination of the medial
tongue of skin and soft tissue left behind by toe
harvest a cross-toe flap from the plantar surface
of the second toe.
• Alternatively, the remaining skeleton can be
shortened to allow donor site closure with only
the medial great-toe skin flap.

• Figure 173-20 If the medial fold of the nail is
carefully reconstructed, appearance is
greatly improved. (Courtesy of Neil Jones,
MD.)
• Figure 173-21 Degloved thumb with bone
graft in place before completion of
reconstruction with toe transfer. (From
Urbaniak JR: Other microvascular
reconstruction of the thumb. In Green DP,
ed: Operative Hand Surgery. New
York,Churchill Livingstone, 1988:1319.)

• Figure 173-27 Long-term follow-up photographs after wraparound procedure (A)
and trimmed great-toe procedure (B and C). (Courtesy of Neil Jones, MD.)

Trimmed great-toe flap
• The trimmed great-toe flap was first described in the late
1980s.
• This technique has the advantage of the wraparound great-
toe flap, namely, better size match of the contralateral
thumb, but avoids the disadvantage of lack of mobility and
growth potential.
• The trimmed toe flap is harvested with both the proximal
and distal phalanges.
• The circumferences of the soft tissues and the bone are
reduced to match the circumference of the contralateral
normal thumb.
• With this technique, joints and epiphyses are preserved.
• The indications for this technique include those for the
whole great-toe and wraparound techniques where better
size match of the contralateral normal thumb is desired.

• Figure 173-22 Marking for osteotomy of the donor toe for trimmed toe technique. A, Dorsal view.
(From Upton J, Mutimer K: A modification of the great-toe transfer for thumb reconstruction. Plast
Reconstr Surg 1988;82:535-539.) B, Lateral view of osteotomies. (From Wei FC, Chen HC, Chuang
CC, Noordhoff M: Reconstruction of a thumb with a trimmed-toe transfer technique. Plast Reconstr
Surg 1988;82:506-513.)

FLAP DISSECTION
• Markings for the trimmed great-toe technique are similar
to those for the wraparound technique.
• The medial proximally based skin flap is elevated off of the
underlying periosteum, with care being taken to preserve
the medial neurovascular structures of the toe.
• A proximally based flap consisting of periosteum and the
medial collateral ligament of the IP joint of the toe is then
elevated off of the underlying bone structures.
• The circumference of the phalanges is reduced by making a
longitudinal osteotomy in the sagittal plane.
• The toe is harvested and inset in a fashion similar to that of
the whole great-toe technique.
• Skin closure and management of the nail plate and
eponychial fold are similar to those of the wraparound
great-toe flap. The donor site closure is identical to that for
the wraparound flap.

Second-Toe to Thumb Transfer
• Transfer of the second toe to the hand was first described
in China in 1973.
• This technique carries with it multiple advantages that
make it an excellent option for microsurgical thumb
reconstruction.
• The second toe's minimal donor site impact, excellent
appearance, and superb function after transfer into the
thumb position make it the preferred digit for toe to thumb
transfer.
• The use of the second toe minimizes donor site problems
associated with toe transfer, which can be both functionally
and socially significant.
• After transfer of the second toe, the overall contour of the
foot is nearly normal. absence of this toe is hardly
noticeable on casual observation.
• Available skeletal length of the donor toe.

• Figure 173-24 Dissected second toe before transfer. (Courtesy of
Neil Jones, MD.)

Disadvantages
• Small size of the donor. This makes for a
thumb that is narrower and weaker, and
therefore potentially less functional, than one
reconstructed with a great toe.
• lack of soft tissue available for coverage of
interosseous muscles and bone when a long
length of metatarsal is used.

• Figure 173-26 Thumb extension (A) and opposition (B) after
microvascular toe to thumb transfer.

• Figure 173-18 Appearance of the foot after harvest of the great toe
(A) and second toe (B). C, Note the minimal impact on appearance
of the foot after second-toe harvest. (Courtesy of Neil Jones, MD.)

POSTOPERATIVE MANAGEMENT
• Critical to the success of microvascular thumb reconstruction
is proper postoperative care.
• Thumb is placed into a splint that provides immobilization
without constricting the thumb.
• Circumferentially wrapped dressings of gauze or other
materials should not be used on the inner layers of the splint
to avoid constriction.
• The splint should leave the tip of the thumb visible for
postoperative monitoring of thumb perfusion.
• The donor lower extremity is placed into a posterior splint.
• Both extremities are elevated during the first 2 weeks to
minimize postoperative edema and venous congestion.
• Flap monitoring during the first 48 hours after surgery must
be frequent.

Cont...
• Many methods have been devised to automate monitoring
of the flap's vascular status postoperatively, including
implantable Doppler devices, laser flowmetry, and pulse
oximetry.
• The most reliable method of evaluation is hourly visual
inspection of the flap for color and quality of capillary refill
during the first 2 postoperative days.
• if flap perfusion is in question, urgent return to the
operating room with exploration of the anastomosis is
imperative for flap salvage.
• The first 3 to 5 postoperative days are spent in a warm
room to minimize vasoconstriction, and adequate hydration
of the patient is ensured.
• Anticoagulation of low-molecularweight dextran and
aspirin are given.

Cont...
• Intravenous antibiotics, which are administered
intraoperatively, are also given during the first 5 to 7
postoperative days.
• At around postoperative day 5, the dressings on the upper
extremity are changed, and a well-padded splint is
reapplied.
• Sutures are removed from the hand and foot on or around
postoperative day 14.
• If pins were used for osteosynthesis or to support another
method of osteosynthesis such as interfragmentary wiring,
they are removed when there is clinical and radiographic
evidence of stability and healing of the bone.

Rehabilitation
• Requires intensive postoperative therapy to maximize the final
result.
• The therapy protocol must be individualized for each case but must
address tendon gliding, recovery of nerve function, and
management of soft tissue issues (such as edema, scarring, and
joint stiffness).
• Limitation on timing and aggressiveness of the therapy protocol will
be dictated by skeletal stability and wound healing, which vary from
case to case.
• Wei has advocated a rehabilitation protocol that begins on the first
postoperative day with flap observation and psychological support
provided by the hand therapist and early passive mobilization of the
reconstructed thumb beginning on postoperative day 4.
• Active range-of-motion exercise is then started during the fifth
postoperative week.
• Recovery of sensibility after toe transfer is a somewhat slow
process that tends to reach a maximum at about 2 years
postoperatively

Complications
 ACUTE COMPLICATIONS
• Anesthetic complications
• Infection
• Bleeding
• Wound healing
complications
• Thrombosis of
microvascular anastomosis
• Flap necrosis
• Rupture of nerve repairs
• Rupture of tendon repairs
 CHRONIC COMPLICATIONS
• Tendon adhesion
• Joint stiffness
• Flexion contracture
• Poor recovery of sensibility
• Delayed union or nonunion
of osteosynthesis

Thank you