Long-term results of finger reconstruction with microvascular toe transfers after trauma

Free neurovascular toe-(joint)-transfers compared to alternative reconstructive procedures for amputation injuries of two and tripartite fingers with substance loss

BACKGROUND

Complex injuries of the hand frequently result in loss of essential functional features. Common reconstructive procedures for soft tissue defects of the thumb or phalanges are locoregional flaps like Moberg-, Foucher-, Cross-Finger- or Littler flaps. Microneurovascular toe (joint-) transfers complete the arsenal of operative reconstructive procedures and allow for most detailed reconstructions. Our experiences with free toe transplants are reported and diversely discussed regarding contending procedures.

METHODS

From 2010 until 2019 14 patients who received emergency or elective partial or complete toe transfers were compared with a control group (n = 12) treated with contending reconstructive procedures. Aim of the reconstructions was to cover the defect with well-vascularized, sensate tissue, while preserving length and range of motion in a reliable manner.

RESULTS

The Kapandji score showed a significant difference (p- value = 0.04) with a score of 9.8 in comparison to control group (Kapandji index = 8.0).

CONCLUSION

In our heterogenic patient collective free toe transplants have proven to achieve comparable functional results for reconstruction of two and tripartite phalanxes as opposed to common local reconstructive procedures.

Combined two foot flaps with iliac bone graft for reconstruction of the thumb

The purpose of this report was to retrospectively review the results of reconstruction of the thumb by use of combined two foot flaps with an iliac bone graft. From 2009 to 2014, nine patients with traumatic amputation of the thumb had their thumbs reconstructed. The two flaps were based on one pedicle. All flaps survived completely. Patients were followed for a mean of 15.6 months (range, 6-35 months). The appearance of the reconstructed thumb was comparable to a normal one, except for one thumb which required debulking. The appearance of the nail was satisfactory without deformity. The range of joint motion was satisfactory. The two point discrimination of the pulp ranged from 6 mm to >15 mm. The Michigan Hand Questionnaire outcome score was a mean of 76.2 ± 11.3 points and the Maryland foot rating score a mean of 94.8 ± 3.4 points. The combined two foot flaps with iliac bone graft might provide an option for the reconstruction of the thumb.

LEVEL OF EVIDENCE

III.

One-stage cosmetic finger reconstruction using a second toe island flap containing terminal branches of the toe artery

INTRODUCTION

A finger reconstructed by toe transfer may have morphological defects. We report the results of second toe transfer for 1-stage finger reconstruction with an island flap based on terminal branches of the toe artery.

HYPOTHESIS

The technique can improve the morphological outcomes of reconstructed fingers.

MATERIALS AND METHOD

Between January 2008 and June 2011, toe-to-finger transfer was performed for 36 fingers in 31 patients. An island flap containing terminal branches of the toe artery was embedded in the neck of the second toe to eliminate the morphological defect caused by stenosis in that area.

RESULTS

All reconstructed fingers and all flaps survived. No donor site complications occurred. The mean follow-up was 8 months (range, 5 to 25 months). The morphology of the reconstructed finger was close to that of a normal finger, and a natural transition could be observed in the finger pulp, the finger neck, and the junction between the toe and the finger. Sensory recovery of the finger pulp ranged from S1 to S3+. The mean pinch strength of the reconstructed fingers was 48% to 60% of that of the contralateral side. The mean DASH scores were 52.9, 48.9, and 46.0 for patients that had the index, third, and fourth fingers reconstructed, respectively, and the lowest mean aesthetic score was 70.

DISCUSSION

The method provides good aesthetic and functional outcomes, and overcomes aesthetic difficulties associated with other methods of toe transfer for finger reconstruction.

Long-term effects of toe transfers on the donor feet

The purpose of this study was to assess the long-term consequences to the donor site of microvascular transfer of one or two toes. This was achieved retrospectively by patient-reported, clinician-based and functional testing. Weight-bearing radiographs were taken of both feet. Seventy-four patients (80 feet, 84 transferred toes) participated in this study. After a median of 16 years follow-up, most patients reported no or only minor complaints concerning the donor site. Cold intolerance and pain during exertion were the most commonly reported complaints. According to the two functional scores used, 92% of patients reported no or minor complaint and 83% of patients received a good result at the donor feet. Maintaining first ray alignment and avoiding early postoperative complications predicted a better outcome. Even though donor site ramifications should be expected after microvascular transfer of toes, patient satisfaction remains high.

Risk factors for reexploration in toe-to-hand transfer: a multivariate analysis of 363 cases

BACKGROUND

Reexploration after toe-to-hand transfer increases the risk of failure. In this study, the authors aimed to identify risk factors for reexploration after toe-to-hand transfer.

METHODS

The medical records of 363 patients who underwent single toe-to-hand transfer between 2000 and 2010 were reviewed retrospectively. Patient demographics, clinical data, and operative data were collected, and multivariate analysis was performed.

RESULTS

Of these 363 patients, 299 toes (82.4 percent) had primary success in transplantation. Sixty-four toes required reexploration, of which seven toes failed. The overall success rate was 98.1 percent. Of the 64 toes that required reexploration, arterial spasm was found in 39 (60.9 percent), arterial thrombosis was found in 27 (42.2 percent), and venous thrombosis was found in 16 (25.0 percent). Multivariate logistic regression analysis revealed that postoperative wound infection, metacarpal hand injuries, and preceding flap coverage were independently associated with reexploration.

CONCLUSIONS

Reducing reexploration in toe-to-hand transfer may be facilitated by managing or avoiding these risk factors. Particular attention must be paid to avoid postoperative wound infection, which was the single greatest factor contributing to reexploration (adjusted OR, 12.6).

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.