Reconstruction of phalangeal articulations of the hand with vascularised phalangeal articulations of foot

Rationalizing the Vascular Anatomy for Oblique Osteotomy of the Metatarsal Head during Toe/Joint Transfers of the Metatarsophalangeal Joint

Background

The metatarsophalangeal joint (MTPJ) of the lessor toe has been used to reconstruct the metacarpophalangeal joint. When an oblique osteotomy of the metatarsal head is performed, the orientation of the vascular pedicle is crucial to preserve the blood supply to the MTPJ. This study was conducted to identify the path of the nutrient artery to the MTPJ.

Methods

We reviewed our operative records in consecutive series of 45 patients during toe or joint harvest. Retrograde dissection of the vascular pedicle was performed starting from the distal communicating artery at the first webspace toward the first dorsal metatarsal and first plantar metatarsal arteries. All the vessels related to the MTPJ were explored and ligated if the MTPJ was not included in the flap.

Results

The condylar branches to the proximal phalanx and the metaphyseal branches to the second metatarsus were barely identifiable during the dissections. The articular branch running perpendicularly from the plantar artery toward the plantar surface of MTPJ was verified in all cases. The articular branches originated either from the first plantar metatarsal artery (92.1%) or from the tibial plantar digital artery (7.9%). The external diameter of the articular branches was around 0.5-1 mm. When the articular branch was included and preserved, the metatarsal heads oozed immediately after the flap was reperfused.

Conclusions

The study demonstrated the constant and sizable articular branch of the MTPJ that originates from the plantar artery system. The consistency of the vascular anatomy enables oblique osteotomies of the metatarsal head to be performed without fear of injury to the pedicle.

Chimeric Free Vascularized Metatarsophalangeal Joint With Toe Fillet Flap: A Technique for Reconstruction of the Posttraumatic Metacarpophalangeal Joint With Concomitant Soft Tissue Defect

For painful, dysfunctional, posttraumatic metacarpophalangeal (MCP) joints, the free vascularized toe joint transfer may represent a good solution. Successful reconstruction is potentially limited, however, by 2 features of the traditional vascularized metatarsophalangeal (MTP) transfer: inadequate arc of flexion and insufficient soft tissue coverage. The solution to both of these dilemmas lies in the manner of utilizing the donor site. Because of its innate hyperextensibility, rotating the MTP 180° volar to dorsal provides the greatest arc of flexion in the reconstructed MCP. Excellent soft tissue coverage can be provided by elevating the skin paddle of the transferred second toe as a chimeric fillet flap, based on the tibial plantar digital artery.

Possibility of the hamatum carpometacarpal joint as a new joint donor site for interphalangeal joint restoration

OBJECTIVE

This research investigates the anatomic basis for the repair and reconstruction of hand joints using transposition of the carpometacarpal (CMC) joint of the hamatum.

METHODS

The morphology and structure of the CMC joints of the hamatum and the base joints of the middle phalanx were observed on 22 freshly frozen wrist specimens at Shanghai 6th People's Hospital Research Institute of Microsurgery. The volar dorsal dia, radioulnar dia, depth of concave, and area of the joints were measured. Data were obtained through statistical analysis, and the resemblance of joints was compared in terms of morphology, structure, area, length, and diameter.

RESULTS

The radioulnar dia of the CMC joints of the hamatum (13.54 ± 1.15 mm) did not exhibit any evident differences in the middle phalanx of the forefinger, middle finger, and ring finger, and in the distal phalanx of the thumb. The volar dorsal dia of the CMC joints of the hamatum (10.71 ± 0.93 mm) exhibited an evident difference in the middle phalanx of the ring finger. In all fingers, the depth of the ulnar and radial concave of the CMC joints of the hamatum (1.30 ± 0.08 and 0.95 ± 0.05 mm, respectively) and the area of the CMC joints of the hamatum (139.89 ± 5.44 mm(2)) showed an evident difference.

CONCLUSION

The CMC joint of the hamatum could be considered a new and viable joint donor site that could be used to repair and reconstruct the base joints of the middle phalanx.

[The vascularized articular transfers from the foot]

Complete destruction of the PIP or MCP joint space can be treated by a vascularized transfer from the foot in selected patients. The surgical technique for PIP and MTP vascularised transplantation is described with special emphasis on recent improvements (use of a short vascular pedicle, refinements in donor site reconstruction). Results of a series of 50 transfers performed between 1992 and 2009 are presented. PIP transfer was performed in 37 patients, at an average age of 18.3 years (range 3 to 40) leading to an average active ROM of 44° (0-80), with a lag of extension of 34.2° (0-80). MCP transfer was performed in 12 patients (13 transfers), at an average age of 21.3 years (range 3 to 40) leading to an average range of motion of 60° (35-80), with a lag of extension of 18.6° (0-30). None of the reconstructed articulations was painful. On the plain radiographs, no degradation of the joint space of the transferred articulations was noted. Within the pediatric population, the growth potential was preserved, signing the perenniality of the vascularization of the transfers. When faced to a complete joint destruction involving either the PIP or the MCP of the long fingers, reconstruction can be achieved by the mean of a vascularized joint transfer. The range of motion obtained with these transfers is not superior to what is observed after arthroplasty but it will persist with time. Therefore, even it is a technically demanding option, it should remain in our armamentarium as an alternative to joint fusion or joint arthroplasty.

Proximal Interphalangeal Joint Replacement with Surface Replacement Arthroplasty (SR-PIP): Functional Results and Complications

The purpose of the study was to investigate patients with proximal interphalangeal (PIP) joint replacements regarding postoperative function, pain, complications and incidence of reoperations. From 2000 to 2007, 23 patients (11 male, 12 female) with an average age of 47 years (19-72 years) who had symptomatic posttraumatic (15) or idiopathic arthritis (nine) in 24 PIP joints underwent unconstrained PIP joint replacements (formerly AVANTA, now Small Bone Innovations(TM)). All 23 patients were instructed in special hand exercises starting the first postoperative day. Thirteen of 23 patients had previous operations. The median history of pain was 12 months (2-120). Fourteen of 24 prostheses needed reoperations (58%): teno-arthrolysis (9×), PIP tenodesis (one in three with swan neck deformity) and explantation (four with infections/loosening). The four explantations resulted in a PIP joint arthrodesis in all cases. Twenty-two patients were available for follow-up at an average of 27 months (4-73 months) postoperatively. The median postoperative pinch grip was 7.6 lbs (4-28 lbs), and the disabilities of the arm, shoulder and hand score was 24 (1-58). The active range of motion of the PIP joint was 33° preoperatively (min 0°, max 75°) and 54° postoperatively (min 0°, max 90°). On the Visual Analogue Pain Scale (VAS, range 0-10), seven patients had mild (VAS 1-3) and four moderate pain (VAS 4-7) in the finger on exercise. Seventy percent were overall satisfied with operation and functional results. The results of surface replacement arthroplasty of the PIP joint are overall satisfying; however, postoperative complications and incidence of reoperations are noticeable and should be mentioned to the patients in the preoperative setting.