Isokinetic assessment of long-term functional donor site morbidity after radial forearm free flap harvest

Abstract

Objective: The radial forearm free flap (RFFF) is widely used in head and neck reconstruction, but potential long-term donor site functional morbidity remains debated. This study aimed to evaluate long-term forearm, hand, and wrist function utilising a novel dynamic biomechanical approach (isokinetic muscle strength measurement) alongside conventional static tests and assess their impact on quality of life (QoL) and activities of daily living (ADL).

Materials and Methods: Twenty-one patients with a minimum six-months follow-up after RFFF harvest were evaluated. Biomechanical measurements were performed to evaluate forearm, wrist, and hand functions. Quality of life (QoL) and activities of daily living (ADL) were assessed using validated tools. Association between biomechanical parameters and QoL and ADL scores were investigated.

Results: No statistically significant long-term decreases were observed in grip strength or wrist ROM on the operated side. While conventional static testing revealed significant decreases in tip-to-tip and palmar pinch strengths (p<0.05), isokinetic evaluation demonstrated that overall dynamic muscle strength was fundamentally preserved. Importantly, the objectively measured decreases in pinch strength and isolated extensor peak torque showed no statistically significant correlation with the QoL and ADL outcomes.

Conclusion: Long-term QoL and the ability to perform daily activities do not deteriorate following the RFFF harvest. Although static biomechanical testing may identify minor, subclinical decreases in specific pinch strengths, the novel application of isokinetic testing confirms that the overall dynamic muscle strength and function of the forearm and wrist are preserved.

Keywords

• free tissue flaps;
• donor site morbidity
• muscle strength dynamometer
• hand strength
• quality of life
• postoperative complications

References

1. Urken ML, Harris JR. Radial forearm. In: Urken ML, Cheney ML, Blackwell KE, Harris JR, Hadlock TA, Futran N, editors. Atlas of regional and free flaps for head and neck reconstruction: Flap harvest and insetting. 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2012: 176-205. google scholar
2. Taghinia AH, Upton J. Radial Forearm Flap. In: Wei FC, Mardini S, editors. Flaps and Reconstructive Surgery. 2nd ed. Edinburgh: Elsevier/Saunders, 2017: 525-39. google scholar
3. Shah JP, Patel SG, Singh B. Reconstructive Surgery. In: Shah JP, Patel SG, Singh B, editors. Jatin Shah’s Head and Neck Surgery and Oncology. 4th ed. Philadelphia: Elsevier/Mosby, 2012:753-93 google scholar
4. Brown MT, Couch ME, Huchton DM. Assessment of donor-site functional morbidity from radial forearm fasciocutaneous free flap harvest. Arch Otolaryngol Head Neck Surg 1999;125(12):1371-4. google scholar
5. Skoner JM, Bascom DA, Cohen JI, Andersen PE, Wax MK. Short-term functional donor site morbidity after radial forearm fasciocutaneous free flap harvest. Laryngoscope 2003;113(12):2091-4. google scholar
6. Orlik JR, Horwich P, Bartlett C, Trites J, Hart R, Taylor SM. Long-term functional donor site morbidity of the free radial forearm flap in head and neck cancer survivors. J Otolaryngol Head Neck Surg 2014;43:1. google scholar
7. Riecke B, Kohlmeier C, Assaf AT, et al. Prospective biomechanical evaluation of donor site morbidity after radial forearm free flap. Br J Oral Maxillofac Surg 2016;54(2):181-6. google scholar
8. Riecke B, Kohlmeier C, Kreiker H, et al. Long-term biomechanical analysis of donor site morbidity after radial forearm free flap. J Craniomaxillofac Surg 2015;43(9):1776-80. google scholar

9. de Witt CA, de Bree R, Verdonck-de Leeuw IM, Quak JJ, Leemans CR. Donor site morbidity of the fasciocutaneous radial forearm flap: what does the patient really bother? Eur Arch Otorhinolaryngol 2007;264(8):929-34. google scholar
10. Bohannon RW. Dynamometer measurements of hand-grip strength predict multiple outcomes. Percept Mot Skills 2001;93(2):323-8. google scholar
11. Fess EE, Moran CA. Clinical assessment recommendations. Garner: American Society of Hand Therapists; 1981. google scholar
12. Adas RT, Kurdak SS. İzokinetik dinamometre ile yapılan ölçümlerde farklı eklemlere ait yük aralığının tespiti. ÇÜ Yüksek Lisans Tezi, Adana, 174s. 2008. google scholar
13. Bohannon RW. Grip strength: a summary of studies comparing dominant and nondominant limb measurements. Percept Mot Skills 2003;96(3 Pt 1):728-30. google scholar
14. Crosby CA, Wehbe MA, Mawr B. Hand strength: normative values. J Hand Surg Am 1994;19(4):665-70. google scholar
15. Eksioglu M. Normative static grip strength of population of Turkey, effects of various factors and a comparison with international norms. Appl Ergon 2016;52:8-17. google scholar
16. Forthomme B, Croisier J-L, Foidart-Dessalle M, Crielaard J-M. Isokinetic assessment of the forearm and wrist muscles. Isokinet Exerc Sci 2002;10(3):121-8. google scholar
17. Incel NA, Ceceli E, Durukan PB, Erdem HR, Yorgancioglu ZR. Grip strength: Effect of hand dominance. Singapore Med J 2002;43(5):234-7. google scholar
18. Petersen P, Petrick M, Connor H, Conklin D. Grip strength and hand dominance: Challenging the 10% rule. Am J Occup Ther 1989;43(7):444-7. google scholar
19. Roberts HC, Denison HJ, Martin HJ, Patel HP, Syddall H, Cooper C, et al. A review of the measurement of grip strength in clinical and epidemiological studies: Towards a standardised approach. Age and Ageing 2011;40(4):423-9. google scholar
20. Richardson D, Fisher SE, Vaughan ED, Brown JS. Radial forearm flap donor-site complications and morbidity: a prospective study. Plast Reconstr Surg 1997;99(1):109-15. Timmons MJ, Missotten FE, Poole MD, Davies DM. Complications of radial forearm flap donor sites. Br J Plast Surg 1986;39(2):176-8. google scholar
21. Chen CM, Lin GT, Fu YC, Shieh TY, Huang IY, Shen YS, et al. Complications of free radial forearm flap transfers for head and neck reconstruction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;99(6):671-6. google scholar
22. Jaquet Y, Enepekides DJ, Torgerson C, Higgins KM. Radial forearm free flap donor site morbidity: ulnar-based transposition flap vs split-thickness skin graft. Arch Otolaryngol Head Neck Surg 2012;138(1):38-43. google scholar
23. Avery CM, Pereira J, Brown AE. Suprafascial dissection of the radial forearm flap and donor site morbidity. Int J Oral Maxillofac Surg 2001;30(1):37-41. google scholar
24. Bootz F, Biesinger E. Reduction of complication rate at radial forearm flap donor sites. ORL J Otorhinolaryngol Relat Spec 1991;53(3):160-4. google scholar
25. Ito O, Igawa HH, Suzuki S, Muneuchi G, Kawazoe T, Saso Y, et al. Evaluation of the donor site in patients who underwent reconstruction with a free radial forearm flap. J Reconstr Microsurg 2005;21(2):113-7. google scholar
26. Loeffelbein DJ, Al-Benna S, Steinstrasser L, Satanovskij RM, Rohleder NH, Mucke T, et al. Reduction of donor site morbidity of free radial forearm flaps: What level of evidence is available? Eplasty 2012;12:e9. google scholar
27. Brown MT, Cheney ML, Gliklich RL, Sheffler LR, Varvares MA. Assessment of functional morbidity in the radial forearm free flap donor site. Arch Otolaryngol Head Neck Surg 1996;122(9):991-4. google scholar
28. de Bree R, Hartley C, Smeele LE, Kuik DJ, Quak JJ, Leemans CR. Evaluation of donor site function and morbidity of the fasciocutaneous radial forearm flap. Laryngoscope 2004;114(11):1973-6. google scholar
29. Ho T, Couch M, Carson K, Schimberg A, Manley K, Byrne PJ. Radial forearm free flap donor site outcomes comparison by closure methods. Otolaryngol Head Neck Surg 2006;134(2):309-15. google scholar
30. Toschka H, Feifel H, Erli HJ, Minkenberg R, Paar O, Riediger D. Aesthetic and functional results of harvesting radial forearm flap, especially with regard to hand function. Int J Oral Maxillofac Surg 2001;30(1):42-8. google scholar
31. Chau J, Harris J, Nesbitt P, Allen H, Guillemaud J, Seikaly H. Radial forearm donor site: comparison of the functional and cosmetic outcomes of different reconstructive methods. J Otolaryngol Head Neck Surg 2009;38(2):294-301. google scholar
32. Lutz BS, Wei FC, Chang SC, Yang KH, Chen IH. Donor site morbidity after suprafascial elevation of the radial forearm flap: a prospective study in 95 consecutive cases. Plast Reconstr Surg 1999;103(1):132-7. google scholar
33. Sardesai MG, Fung K, Yoo JH, Bakker H. Donor-site morbidity following radial forearm free tissue transfer in head and neck surgery. J Otolaryngol Head Neck Surg 2008;37(3):411-6. Schwarzer C, Mucke T, Wolff KD, Loeffelbein DJ, Rau A. Donor site morbidity and flap perfusion of subfascial and suprafascial radial forearm flaps: A randomized prospective clinical comparison trial. J Craniomaxillofac Surg 2016;44(9):1299-304. google scholar
34. Bardsley AF, Soutar DS, Elliot D, Batchelor AG. Reducing morbidity in the radial forearm flap donor site. Plast Reconstr Surg 1990;86(2):287-94. google scholar
35. Swanson E, Boyd JB, Manktelow RT. The radial forearm flap: reconstructive applications and donor-site defects in 35 consecutive patients. Plast Reconstr Surg. 1990;85(2):258-66. google scholar
36. Boorman JG, Brown JA, Sykes PJ. Morbidity in the forearm flap donor arm. Br J Plast Surg 1987;40(2):207-12. google scholar
37. Bohannon RW, Bear-Lehman J, Desrosiers J, Massy-Westropp N, Mathiowetz V. Average grip strength: a meta-analysis of data obtained with a Jamar dynamometer from individuals 75 years or more of age. J Geriatr Phys Ther 2007;30(1):28-30. google scholar
38. Lane JC, Swan MC, Cassell OC. Closure of the radial forearm donor site using a local hatchet flap: analysis of 45 consecutive cases. Ann Plast Surg 2013;70(3):308-12. google scholar
39. Schuind FA, Mouraux D, Robert C, Brassinne E, Remy P, Salvia P, et al. Functional and outcome evaluation of the hand and wrist. Hand Clin 2003;19(3):361-9. google scholar
40. Agirman M, Kara A, Durmus O, Saral I, Cakar E. Isokinetic evaluation of wrist muscle strength in patients of carpal tunnel syndrome. Eklem Hastalik Cerrahisi 2017;28(1):41-5. google scholar