Microsurgical Restoration of Distal Digital Function

Fingertip reconstruction using free toe tissue transfer without venous anastomosis

BACKGROUND

This study was designed to introduce the feasibility of toe tissue transfer without venous outflow for fingertip reconstruction.

METHODS

Five cases of fingertip defects were treated successfully with this method. Four cases were traumatic fingertip defects, and one case was a hook-nail deformity. The lateral pulp of a great toe or medioinferior portion of a second toe was used as the donor site. An arterial pedicle was dissected only within the digit and anastomosis was performed within 2 cm around the defect margin. The digital nerve was repaired simultaneously. No additional dissection of the dorsal or volar pulp vein was performed in either the donor or recipient sites. Other surgical procedures were performed following conventional techniques. Postoperative venous congestion was monitored with pulp temperature, color, and degree of tissue oxygen saturation. Venous congestion was decompressed with a needle-puncture method intermittently, but did not require continuous external bleeding for salvage.

RESULTS

Venous congestion was observed in all the flaps, but improved within 3 or 4 days postoperatively. The flap size was from 1.5×1.5 cm(2) to 2.0×3.0 cm(2). The mean surgical time was 2 hours and 20 minutes. A needle puncture was carried out every 2 hours during the first postoperative day, and then every 4 hours thereafter. The amount of blood loss during each puncture procedure was less than 0.2 mL. In the long-term follow-up, no flap atrophy was observed.

CONCLUSIONS

When used properly, the free toe tissue transfer without venous anastomosis method can be a treatment option for small defects on the fingertip area.

Posttraumatic finger reconstruction with microsurgical transplantation of toes

This article outlines current methods of toe transplantation as applied to posttraumatic finger reconstruction (excluding the thumb). Key points that are important during the initial assessment and surgical treatment of such injuries are addressed. Reconstructive options for distal and proximal finger injuries, single and multiple finger injuries, and metacarpal hand injuries are presented, and the timing of toe transplantation procedures is discussed. Finally, additional concepts and techniques that, with experience, have proved useful for optimizing functional and esthetic results are highlighted, along with schemes for motor and sensory rehabilitation.

Second toe to index finger transfer

Between April 1994 and May 1998, 15 amputated index fingers were treated based on three classifications: group 1 consisted of patients with index finger defects immediately proximal to, yet including, the distal interphalangeal joint, group 2 were those patients with defects from the proximal part of the distal interphalangeal joint to the distal part of the proximal interphalangeal joint and group 3 comprised patients with more proximal defects than group 2. With a total of six men and nine women, seven cases were included in group 1, five in group 2 and three in group 3. For the patients in groups 1 and 2, only a partial length of the second toe was transferred to the index finger, whereas in group 3 the total length of the toe needed to be transferred. The results can be summarised as follows:1. The two-point discrimination of the reconstructed index tip was 2.2 mm for group 1, 2 mm for group 2 and 2.3 mm for group 3.2. In group 1, the average range of motion in the transferred toe was 43.8>> in the distal interphalangeal joint. In groups 2 and 3, the average range of motion in the transferred toe was 30>> and 30.7>> in the distal interphalangeal joint, and 50>> and 39.3>> in the proximal interphalangeal joint, respectively.3. When compared with the contralateral index finger, the pinching power was measured at 83% in group 1, 70% in group 2 and 60% in group 3.4. Excellent results were obtained in group 1, good results in group 2 and fair results in group 3. Accordingly, the more proximal the defect in the index finger, the less satisfactory the result obtained.

Reconstruction of bilateral metacarpal hands with multiple-toe transplantations

Bilateral metacarpal hands, if not treated properly, leave a patient without prehensile ability in both hands. Since 1990, six patients with bilateral metacarpal hands caused by accidents have undergone reconstruction with multiple-toe transplantations. Four or five toes were used for each patient, with a total of 27 toes transplanted to the hands. There was no toe loss. One nonunion in a middle-finger reconstruction was treated successfully with bone grafting. Secondary operations for functional improvement included one joint fusion and one flexor tendon tenolysis. Only one patient required excision of a plantar callus 42 months postoperatively, whereas the other five patients reported no major donor-site problems in an average 57 months of follow-up time. The six patients continue all their daily activities independently. Although their jobs were changed, all adult male patients were able to return to regular work. Principles of reconstruction to achieve satisfying prehensile function combined with minor donor-site morbidity in bilateral metacarpal hands include an adequate soft-tissue coverage before toe transplantations, selection of digits to be reconstructed based on functional and individual requirements, selection of toes and number of toes to be harvested based on consideration of usefulness for the hands and of foot morbidity, and consideration of thenar function in planning the sequence of transplantations. In conclusion, given thorough planning, multiple toe-to-hand transplantations can provide adequate prehensile function in reconstructed bilateral metacarpal hands with acceptable donor-site morbidity.

Toe transplantation for isolated index finger amputations distal to the proximal interphalangeal joint

Functional deficit following single distal index finger amputations has been considered insignificant, and reconstruction is usually not recommended. Herein, 19 cases of second toe transplantation for reconstruction of isolated index finger amputation distal to the proximal interphalangeal joint are presented with long-term functional results. There are 14 men and 5 women. The average age was 26 years. The toe transplantations were performed either as a primary procedure (5 patients) while the wounds were still open or as a secondary procedure (14 patients) after the wounds healed. In 11 patients, the dominant hand was involved. All toes survived completely, although re-exploration was required in three cases (16 percent). The functional evaluation included (1) sensory recovery, where the average static and moving two-point discrimination were 8 mm (range 4 to 15 mm) and 6 mm (range 2 to 15 mm); (2) motor function, where the average of index-thumb pulp-to-pulp pinch compared with the normal hand was 67.5 percent (range 36 to 96 percent); (3) average range of motion in index finger joints (extension/flexion), where metacarpophalangeal joint was 14/90, proximal interphalangeal joint was 0/94, and distal interphalangeal joint was 19/38; and (4) functional and cosmetic results, where percentage of involvement in daily activities and functional capacity of the reconstructed index were 69 percent and 70.5 in average, respectively, over a total score of 100. Average scores of aesthetic appearance and acceptability of donor-site deformity were 74 and 87.5 over a total score of 100, respectively. Toe transplantation for distal index finger amputations improved hand function when performed in selected patients with specific job requirements or high motivation.

Aesthetic fingertip reconstruction with a free vascularized nail graft: a review of 60 flaps involving partial toe transfers

Microsurgical toe transfer is an established procedure for functional reconstruction of fingers. However, even if the functional loss is minimal, the fingertip defect is often a large problem for patients for not only functional reasons but also aesthetic reasons. In these patients, although the normal appearance of the fingertip is very important, total toe transfer is not acceptable because of resection of an entire toe. With this background, partial toe transfer techniques have greatly progressed. On the other hand, various types of innervated finger flaps also have been developed in hand surgery. Based on this progress, we developed the combined technique of innervated finger flaps in the hand and osteo-onychocutaneous flaps from the toe. This technique provides better aesthetic results in fingertip reconstruction, thus broadening the indications for vascularized nail grafts. We have now experienced 60 flaps in partial toe transfer. In this report, a review of 60 consecutive flaps is presented, and the indications, technique, and postoperative treatment are discussed.

Secondary procedures to improve function after toe-to-hand transfers

From August 1990 to December 1992, 139 toe-to-hand transfers were performed on 99 patients. Crush, avulsion, and combined crush and avulsion were the mechanisms of injury in 92.8% of the cases. Average duration of follow-up was 17 months (1 to 40 months). 133 transfers were successful, an overall survival rate of 95.7%. 19 transfers (14.3%) required secondary procedures for functional improvement. The incidence of secondary procedure on tendon, bone, joint and soft tissue was 9.0%, 1.5%, 2.3% and 3.0% respectively. Flexor tenolysis was the single most common secondary procedure (6.8%). The results of secondary procedures were satisfactory in all but one instance. Transient neurapraxia of an ulnar digital nerve after tenolysis was the only complication of the secondary procedures.

Delayed sensory reeducation after toe-to-hand transfer

The effect of a delayed program of sensory rehabilitation was evaluated in 13 patients with a total of 22 toe-to-hand transfers. Each patient was begun on a protocol of sensory reeducation at a mean of 38 months (range 13-98 months) after the transfer. Home rehabilitation, employing a Disk-Criminator (TM) program, was monitored at monthly intervals by the therapist for a mean of 3.3 months, at which time a final evaluation of sensibility was done. Each of the 22 toe transfers improved by an average of 7 mm in static and 6 mm in moving two-point discrimination. The improvement in two-point discrimination following delayed implementation of sensory reeducation was statistically significant at the P < 0.0001 level.

Microsurgical reconstruction of distal digits following mutilating hand injuries: results in 121 patients

From 1982-1989, 152 mutilated distal digits were reconstructed with microsurgical foot tissue transfers in 121 patients. These various foot tissues included wrap-around flaps or pulp from the great toe, second toe, or third toe, as well as partial toe, nail, web space skin, and other portions of the foot. The reconstructions were carried out primarily and secondarily in 78 and 74 patients respectively. The immediate success rate was 98%. Most of the patients were satisfied with both the cosmetic appearance and the functional result. This relatively minor microsurgical foot tissue transfer proved to be an ideal reconstructive option for distal digital defects.