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Index Finger to First Web Space Stiletto Flap in Patients with Thumb-In-Palm Deformities Secondary to Cerebral Palsy
Taylor Cogsil, MD, Hailey Huddleston, MD; Dan Zlotolow, MD
Hospital for Special Surgery, New York, NY
Introduction:
Patients with spasticity often suffer from thumb-in-palm deformities. After surgical correction of a first web space contracture, there can be a skin deficit requiring a skin graft or flap. The goal of this surgical technique case series was to evaluate the use of a new approach for soft tissue coverage of the first web space borrowing from the techniques employed in arthrogryposis. We hypothesized that an index finger rotational "stiletto flap" to the first web space would provide adequate skin coverage without compromising the achieved thumb abduction in patients with moderate to severe thumb-in-palm deformities secondary to cerebral palsy (CP).
Materials and Methods:
Three cases were performed at our institution between May 2024 and December 2024 (Table 1). A stiletto flap was raised using the skin from the index finger. This was derived from mid-axis, with the base at the radial margin of the thenar crease, and the recipient incision at the thenar crease. Approximately 4-5cm
2 of full thickness tissue was raised down to fascia to preserve any vessels within the flap. The dorsal sensory branch of the digital nerve was preserved. The flap was then rotated into the first web space. The donor site was closed primarily with absorbable suture.
All patients were evaluated for a minimum of three months post-operatively.
Results:
All three patients achieved at least 60 degrees of passive abduction intra-operatively. This resulted in a skin and soft-tissue deficit in the first web space and palm which was filled adequately with the flap. No additional skin grafting or under-correction of the web were required (Figure 1). Flap survival was complete in all 3 cases without complications. There were no instances of correction loss due to soft tissue tethering or contracture within the first three months after surgery.
Conclusions:
An index to first web space stiletto flap provides adequate skin coverage for patients with thumb-in-palm deformities undergoing surgical correction. This can be considered in place of the four-flap z-plasty or the Abdel Ghani flap when treating thumb-in-palm deformities.
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