Vascularised toe proximal interphalangeal joint transfer in posttraumatic finger joint reconstruction: The effect of skin paddle design on extensor lag

Simultaneous or Delayed Free Tissue Transfer in Combination with Replantation Surgery

In hand and upper extremity replantation surgery, simultaneous free flap reconstruction restores the physiologic circulation to the amputated part, ensuring its survival, and promotes wound healing through anatomic restoration. Especially in digit replantation, an arterialized venous flap serves to reconstruct both vessel and soft tissue defects simultaneously. Delayed free flap reconstruction aims to enhance both functional improvement and cosmetic acceptance in a successfully replanted part using flaps that include functioning muscle, bone, joint, nerve, and soft tissue.

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.

Vascularized Toe Proximal Interphalangeal Joint Transfer in Posttraumatic Fingers: Analysis of Prognostic Factors for Suboptimal Outcomes

Background

Posttraumatic finger osteoarthritis of the proximal interphalangeal joint (PIPJ) is a difficult problem. Over the past decade, we have reported several methods for improving the outcomes of vascularized toe joint transfer (VJT). In this study, we focused on determining poor prognostic factors which lead to a suboptimal outcome.

Methods

A consecutive series of patients with posttraumatic osteoarthritis of the PIPJ who received VJT between January 2008 and January 2021 were enrolled in this study. The senior surgeon (Y.-T.L.) performed the surgery in all cases. In this retrospective study, we reexamine the initial trauma-related soft tissue and bony structure injuries of the recipient finger, to assess the baseline tissue quality before VJT. The injuries were classified into five major categories according to their anatomic region. The functional outcome parameters (including range of motion, percentage of use, and extensor lag of the transferred PIPJ) were collected. Univariate and multivariate linear regression analyses were performed using the generalized estimated equation model to identify the correlation between the injury category involved and functional outcome.

Results

A total of 59 digits were enrolled. Our results revealed that the fingers with previous vascular injury that received revascularization procedures had relatively suboptimal functional outcomes. These fingers had a significantly lower percentage of use both before (β = -0.222, P = 0.006) and after (β = -0.177, P = 0.006) receiving secondary procedures to improve functional outcome.

Conclusions

Patients with prior revascularization surgery were associated with a poor functional outcome after VJT.

Minimum 5-Year Follow-Up Assessment of Volar Plate Interposition Arthroplasty for Post-Traumatic Osteoarthritis in Proximal Interphalangeal Joints

This is a retrospective study to evaluate the outcome of volar plate interposition arthroplasty for proximal interphalangeal joint post-traumatic osteoarthritis with a minimum 5-year follow-up. We identified patients receiving volar plate interposition arthroplasty for post-traumatic osteoarthritis in proximal interphalangeal joints. The measurements included the numeric pain scale (on a scale of 0-10), the proximal interphalangeal joint active range of motion, the Michigan Hand Outcomes Questionnaire, the perioperative radiograph of the involved digit, proximal interphalangeal joint stability, and pinch strength. Eight patients with a median age of 44 years old (interquartile range (IQR): 29.3-56.8) were included in this study. The median follow-up period was 6.5 years (range of 5-11 years). The median numeric pain scale improved from 5 (IQR: 4.3-6.0) preoperatively to 0 (IQR 0-0.8) at the follow-up evaluation (p = 0.011). All digits demonstrated stability during manual stress testing compared to their noninjured counterparts. The median active proximal interphalangeal joint arc of motion improved from 25° to 55° (p = 0.011). The pinch strength of the fingers on the injured hand was weaker than those on the contralateral hand (2.2 Kg vs. 3.7 Kg, p = 0.012). We suggested that volar plate interposition arthroplasty may be an alternative surgical option for post-traumatic osteoarthritis in the proximal interphalangeal joints.

Toe-to-Finger Vascularized Joint Transfers for Proximal Interphalangeal Joint Reconstruction: A Systematic Review

Vascularized joint transfer (VJT) from the proximal interphalangeal joint (PIPJ) of the toe is an attractive reconstructive option in cases of nonsalvageable finger PIPJ but is limited by equivocal functional outcomes. This systematic review aims to provide an update on vascularized toe-to-finger PIPJ transfers, examining functional outcomes, complications, and the latest refinements in operative technique. A systematic review of the available literature was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies examining vascularized toe-to-finger PIPJ transfer for post-traumatic indications were included for analysis. Outcomes assessed included postoperative active range of motion, extension lag, and complications. Thirteen studies examining 210 VJTs were analyzed. Five VJTs experienced microsurgical failure giving an overall survival rate of 97.6%. Average postoperative PIPJ active range of motion (ROM) was 40.3° ± 12.9°, with an average extensor lag of 29° ± 10.5° and mean flexion of 68.9° ± 10.9°. For studies reporting complication outcomes, 59/162 complications were seen. No significant differences were seen between studies published prior to 2013 and after 2013 when comparing digital ROM (P = .123), flexion (P = .602), and extensor lag (P = .280). Studies using a reconstructive algorithm based on prior assessment of the donor toe central slip and recipient finger anatomy had significantly improved ROM outcomes (P = .013). Although VJT provides a reliable option for autologous reconstruction in posttraumatic joints, it is limited by impaired postoperative ROM. Careful assessment of the donor toe and recipient finger anatomy followed by systematic and meticulous reconstruction may lead to improved functional outcomes.

Nonvascularized Toe Joint Transfers to the Hand in Young Children: Technique Revisited

BACKGROUND

Small joint reconstruction of the hand poses a significant challenge, especially in children where both functional motion and preservation of the epiphysis are desired. Auto-transplantation of whole joints is the only way to reconstruct a functional joint that maintains growth potential. Historically, nonvascularized toe-to-finger joint transfer has been criticized for high rates of avascular necrosis and joint dissolution, while vascularized transfers seemingly resulted in increased durability of the joint space and epiphysis. However, certain populations remain poor candidates for microvascular reconstruction, such as those with congenital deformities or sequelae from trauma or infection. In our case series, we demonstrate that a simplified nonvascularized surgical technique and careful patient selection can produce stable, functional joints.

METHODS

Nonvascularized toe-to-finger joint transfer was performed in 3 children between the ages of 4 and 6. Reconstructed joints included 2 proximal interphalangeal (PIP) joints and 1 metacarpophalangeal (MCP) joint. Donor grafts consisted of second toe PIP joints harvested en bloc to include the epiphysis of the middle phalanx, collateral ligaments, volar plate, and a diamond-shaped island of extensor tendon with its central slip attachment.

RESULTS

Follow-up ranged from 7 to 29 months. Each patient demonstrated functional improvements in joint motion and stability. Postoperative radiographs confirmed adequate joint alignment and persistence of the joint spaces. Epiphyseal closure was observed in 1 patient as early as 25 months postoperatively.

CONCLUSIONS

Nonvascularized joint transfer should remain a practical consideration for small joint reconstruction of the hand in certain pediatric patients.

A Reversed Inset Toe PIPJ Vascularized Joint Transfer for Finger PIPJ Composite Defect Reconstruction

Free vascularized joint transfers (VJT) are indicated for reconstruction of a composite defect of the finger joints. When the bone defect involves the proximal interphalangeal joint (PIPJ) and the full length of the middle phalanx, using the toe PIPJ with a shorter middle phalanx to reconstruct such a defect will be difficult. In this article, we describe an unusual application to repair the composite defect with a reversed inset of the toe PIPJ, where the proximal phalanx of the toe is placed distally and vice versa.

Non-vascularized partial joint transfer for Finger Proximal Interphalangeal joint reconstruction: a series of 9 patients

INTRODUCTION

Finger proximal interphalangeal joint (PIP) reconstruction after the destruction of parts of the joint remains challenging. Surgical techniques include implant arthroplasty, arthrodesis, free vascularized joint transfer, and non-vascularized bone and joint transfer. This study analyzes our experience after non-vascularized transfer in terms of range of motion, postoperative rehabilitation, and patient satisfaction.

MATERIALS AND METHODS

Between 2009 and 2014, ten patients underwent non-vascularized partial joint transfer for PIP joint reconstruction. One of them was lost to follow-up. Included patients had osteochondral partial joint transplants of 25-50% of the toes (n = 4) and the hand (n = 5). Range of motion (ROM), grip-, and pinch-strength were measured at the last follow-up control and compared to the healthy side. Patients were asked to score the pain at rest/ on load on a visual scale (VAS: 0 = no pain; 10 = excruciating pain). Satisfaction self-assessment was evaluated by asking the patients to grade their postoperative result as excellent, very good, good or poor.

RESULTS

Mean follow-up period was 4.0 years (range 1.2-7.9 years). Mean PIP joint flexion was 93 ± 26° at the last follow-up control. Mean grip- and pinch-strength of the operated side at the last control were, respectively, 43 ± 18 kg and 8 ± 5 kg, close to the healthy side values (45 ± 15 kg and 9 ± 4 kg). Mean pain at rest/on load measured on a visual scale was, respectively, 0.3 ± 1 and 1.8 ± 2. Eight patients (89%) rated their operation as excellent, and one as poor.

CONCLUSION

In this study, non-vascularized partial joint transfer provides a mobile and stable PIP joint 4 years after reconstruction. The surgical technique presented herein is complex depending on additional injuries but results in great patient satisfaction.

Technical keys in maximizing finger proximal interphalangeal joint motion after vascularized toe joint transfers

Vascularized toe joint transfers to the fingers have been performed for more than four decades, but their outcomes are not comparable with implant arthroplasty. Limited range of motion and extensor deficits of about 30° remain major problems with the constructed joints. We observed that the central extensor tendon of the toe is often attenuated proximally in its course on the dorsum of the proximal interphalangeal joint. A tight repair of the toe extensors to finger extensors limits joint motion. We reviewed our surgical techniques with this consideration. Thirty-eight fingers that we followed for 6 to 123 months had active range of motion of the reconstructed proximal interphalangeal joint in the finger of 58° (range 17°-76°) with an extensor deficit of 18° (range 0°-30°). We consider that the extensor mechanism and central slip insertion to the middle phalanx must be reconstructed meticulously to improve joint motion and decrease extension lag, and design of a lateral skin flap paddle to better cover vessels and allow extensor repairs.

Total finger joint arthroplasty with a costal osteochondral autograft: up to 11 years of follow-up

The purpose of this study was to evaluate the mid- to long-term clinical outcomes of total finger joint arthroplasty using a costal osteochondral autograft for joint ankylosis. Twenty-three joints (three metacarpophalangeal joints, 20 proximal interphalangeal joints) in 23 patients (19 men and four women) were treated with a costal osteochondral autograft and were evaluated after a mean follow-up of 77 months (60-138). Mean age was 33 years (18 to 55). Significant improvement in active finger extension/flexion was seen from a preoperative mean of -24°/26° (arc: 2°) to -13°/75° (arc: 63°) at latest follow-up. Mean preoperative Japanese Society for Surgery of the Hand version of the Disability of the Arm, Shoulder and Hand score was initially 24 and improved significantly to 5 at latest follow-up. Conclusion: total finger arthroplasty using a costal osteochondral autograft gave an anatomical and biological reconstruction and provided stable improvement at a mean follow-up of 77 months. Level of evidence: IV.

Functional Improvement with Free Vascularized Toe-to-hand Proximal Interphalangeal (PIP) Joint Transfer

Supplemental Digital Content is available in the text.

Background:

Reconstruction of small joints of fingers is still challenging in hand surgery. Implant arthroplasty and arthrodesis have some limitations in the reconstruction of small finger joints. Free vascularized PIP joint transfer from second toe to finger is a promising autogenous reconstructive alternative.

Methods:

In this prospective study, 7 cases of free vascularized PIP joint transfer were analyzed. The measurements for active and passive range of motion (ROM), grip, and pinch strength has been done preoperatively and 1-year postoperatively. The functional change in daily life quality and work-related activities was evaluated with Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire.

Results:

Mean follow-up period was 20.3 months (12–25). Preoperative mean active and passive ROM values were 3.6° (0–14°) and 11.9° (0–29°), respectively. Postoperative 1-year measurements revealed a mean active ROM of 24.1° and a mean passive ROM of 31.6°. Mean grip and pinch strength increased from 52.1 to 58.6 lbs and from 5.1 to 5.9 lbs, respectively. Mean preoperative and postoperative DASH-scores were 41.3 and 30.3.

Conclusion:

The improvement in ROM, increasing grip strength, and declining DASH scores in our study support that free vascularized joint transfer improves patients’ daily life quality and work-related activities via providing a functional joint if performed with appropriate indications, careful planning, and meticulous surgical execution. Free vascularized joint transfer provides an autogenous, painless, mobile, and stable joint. It also has the advantages of composite tissue reconstruction and lacks the disadvantages of arthrodesis and synthetic joint implants.

The Impact of Microsurgery on Congenital Hand Anomalies Associated with Amniotic Band Syndrome

Supplemental Digital Content is available in the text.

Background:

Amniotic Band Syndrome is a clinical constellation of congenital anomalies characterized by constricting rings, tissue synechiae and amputation of body parts distal to the constriction bands. Involvement of the hand with loss of multiple digits not only leads to devastating deformities but also loss of functionality.

Methods:

In this series, utilizing microvascular transfer of the second toe from both feet, along with local tissue reconfiguration, a tetra-digital hand with simile of normal cascade was reconstructed. A consecutive series of eight children with Amniotic Band Syndrome, younger than two years in age operated on by single surgeon over a twenty five year interval was reviewed.

Results:

There was no flap loss. The hands were sensate with effective simple prehensile function.

Conclusion:

Application of Microvascular toe-to-hand transfer for well selected, albeit severe hand deformity in Amniotic Band Syndrome is a valid surgical concept.

The impact of transferred vascularized toe joint length on motion arc of reconstructed finger proximal interphalangeal joints: a cadaveric study

Vascularized toe joint transfer for finger proximal interphalangeal joint reconstruction can result in sub-optimal arc of motion and extension lag due to inappropriate intercalated bony segment length. We investigated the impact of intercalated segment length on passive arc of motion and extension lag of the reconstructed proximal interphalangeal joint. Cadaveric intercalated joint grafts were harvested from lesser toes and transferred to cadaveric fingers. The pre-determined finger proximal interphalangeal joint defect size was 2 cm. Three different intercalated segment lengths were inserted and resulting proximal interphalangeal joint arc of motion and extension lag were measured. The average arc of motion of finger proximal interphalangeal joints was 81° and 54° for toe proximal interphalangeal joints. Long intercalated segments had an average arc of motion of 30° with 32° extension lag. Equal-length intercalated segments had an average 49° arc of motion with 15° extension lag. Short intercalated segments had an average arc of motion of 71° with 8° extension lag. Shorter intercalated segments provide the greatest reduction in extension lag.

Customizing Extensor Reconstruction in Vascularized Toe Joint Transfers to Finger Proximal Interphalangeal Joints: A Strategic Approach for Correcting Extensor Lag

BACKGROUND

Vascularized toe proximal interphalangeal joint transfer allows the restoration of damaged joints. However, extensor lag and poor arc of motion have been reported. The authors present their outcomes of treatment according to a novel reconstructive algorithm that addresses extensor lag and allows for consistent results postoperatively.

METHODS

Vascularized toe joint transfers were performed in a consecutive series of 26 digits in 25 patients. The average age was 30.5 years, with 14 right and 12 left hands. Reconstructed digits included eight index, 10 middle, and eight ring fingers. Simultaneous extensor reconstructions were performed and eight were centralization of lateral bands, five were direct extensor digitorum longus-to-extensor digitorum communis repairs, and 13 were central slip reconstructions.

RESULTS

The average length of follow-up was 16.7 months. The average extension lag was 17.9 degrees. The arc of motion was 57.7 degrees (81.7 percent functional use of pretransfer toe proximal interphalangeal joint arc of motion). There was no significant difference in the reconstructed proximal interphalangeal joint arc of motion for the handedness (p = 0.23), recipient digits (p = 0.37), or surgical experience in vascularized toe joint transfer (p = 0.25). The outcomes of different techniques of extensor mechanism reconstruction were similar in terms of extensor lag, arc of motion, and reconstructed finger arc of motion compared with the pretransfer toe proximal interphalangeal joint arc of motion.

CONCLUSION

With this treatment algorithm, consistent outcomes can be produced with minimal extensor lag and maximum use of potential toe proximal interphalangeal joint arc of motion.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.