Combined pollicization and toe transfer for thumb reconstruction

Reconstruction of combined thumb amputation at the metacarpal base level and index amputation at the metacarpal level with pollicization and bilateral double toe composite transfer

BACKGROUND

This study aimed to describe the technique and report our experience with the reconstruction of combined proximal thumb amputations at the metacarpal base level and index finger amputation at the metacarpal level with pollicization and bilateral double toe composite transfer.

METHODS

The technique consists of pollicization of the remnant index ray. Then a contralateral composite medial great toe pulp and vascularized second toe proximal interphalangeal joint flap are harvested to reconstruct the metacarpophalangeal joint of the thumb. Subsequently, an ipsilateral composite great toe wrap-around and second toe proximal interphalangeal joint flap are harvested to reconstruct the thumb interphalangeal joint and the distal thumb. A neurotized superthin anterolateral thigh flap is used to reconstruct the ipsilateral toe defect, while the bone defects of the bilateral second toes are reconstructed with corticocancellous iliac crest bone grafts. Between 2010 and 2014, eight patients underwent reconstruction. Four patients could be recalled for follow-up, with a mean duration of 22 months.

RESULTS

All flaps survived. The contour and length of the reconstructed thumbs was similar to the contralateral one. The mean Michigan hand outcomes questionnaire score was 80.5. The mean disabilities of the arm, shoulder and hand score was 7.5. The mean foot and ankle disability index score was 94.2.

CONCLUSIONS

Reconstruction of thumb amputations at the metacarpal base level with pollicization and double toe composite transfer results in excellent contour and functional outcome, with a natural-appearing thumb. In addition, all toes are preserved.

LEVEL OF EVIDENCE

Therapeutic, Level IV.

[Prefabrication of transplants in plastic surgery]

Complex three-dimensional defects with destruction of the external form, loss of functional stability and inner lining are associated with tactical and technical challenges in reconstructive plastic surgery. Causative factors are mutilating infections, resection of malignant tumors and trauma, predominantly located at the aerodigestive junction, the urogenital region and the extremities. Three-dimensional tissue constructions are preformed distant to the defect site allowing safe pedicled or microsurgical transfer into the defect.

The effectiveness of pedicled groin flaps in the treatment of hand defects: results of 49 patients

PURPOSE

Despite the growing number of free and local flaps used for repairing defects of the hand, groin flaps are also still widely used. The aims of this study were to evaluate the outcome of a large series of patients whose defects were covered by pedicled groin flaps, and to find out whether it is still indicated in replacing damaged soft tissue of the hand in the era of microsurgery.

METHODS

From 1982 to 2009, we treated 85 patients with soft tissue defects on the hand and distal forearm with pedicled groin flaps in our department and recorded them in a prospective database. We interviewed and examined 49 patients in this cohort.

RESULTS

The mean age of the 85 patients was 33 years, the male/female ratio was 4:1, the mean hospital stay was 29 ± 13 days, and the mean follow-up was 9 years. The duration to flap division was 24 ± 5 days. Altogether, we performed a mean of 4.6 operations per patient, including thinning of the flap, deepening of the interdigital fold, and stump and flap revisions. One flap loss occurred. Of the 49 patients, results were mostly classified as good, and 82% of patients would undergo the procedure again. The mean Disabilities of the Arm, Shoulder, and Hand score value was 23 ± 17. The Vancouver Scar Scale showed nearly normal height and vascularity of the groin flap (0.2 ± 0.4 and 0.3 ± 0.6, respectively), pigmentation was slightly abnormal (0.8 ± 0.6), and pliability was evaluated between "supple" and "yielding" (1.5 ± 1.2).

CONCLUSIONS

Results achieved with the groin flaps were positive. Most patients were satisfied with the results, and the operation was easily performed when McGregor's recommendations were followed. Nevertheless, considering the high number of secondary operations, the long hospital stay, and immobilization of the arm, groin flaps should be used only when free flaps or regional pedicle flaps are either not feasible or not indicated.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Vascularized bone grafts for upper limb reconstruction: defects at the distal radius, wrist, and hand

Vascularized bone grafts have been successfully applied for the reconstruction of bone defects at the forearm, distal radius, carpus, and hand. Vascularized bone grafts are most commonly used in revision cases in which other approaches have failed. Vascularized bone grafts can be obtained from a variety of donor sites, including the fibula, the iliac crest, the distal radius (corticocancellous segments and vascularized periosteum), the metacarpals and metatarsals, and the medial femoral condyle (corticoperiosteal flaps). Their vascularity is preserved as either pedicled autografts or free flaps to carry the optimum biological potential to enhance union. The grafts can also be transferred as composite tissue flaps to reconstruct compound tissue defects. Selection of the most appropriate donor flap site is multifactorial. Considerations include size matching between donor and defect, the structural characteristics of the graft, the mechanical demands of the defect, proximity to the donor area, the need for an anastomosis, the duration of the procedure, and the donor site morbidity. This article focuses on defects of the distal radius, the wrist, and the hand.

Pollicisation of the index metacarpal based on the first dorsal metacarpal artery

We present our experience of two cases in which we carried out pollicisation of the index metacarpal based on the first dorsal metacarpal artery and venae comitans. Both cases were complex severe hand injuries where the initial injury was the result of a firework exploding while held in the hand. In both cases the radial side of the superficial palmar arch was destroyed by the injury. In both cases there was virtually complete loss of the thumb ray and amputation of the index through the base of the proximal phalanx. A useful opposition post has been created from vascularised index metacarpal with free flap soft tissue reconstruction.