Reconstruction of severe transmetacarpal mutilating hand injuries by combined second and third toe transfer

A Systematic Review of the Outcomes of Microsurgical Toe Transfer for Metacarpal and Metacarpal-Like Hand Deformity

Background: Thumb and multiple finger amputations may result in a metacarpal and a metacarpal-like hand deformity. Toe-to-hand transfer is a recognised treatment strategy for this deformity but has risks and is resource intensive. The aim of this study is to conduct a systematic review of the outcomes of toe-to-hand transfer for traumatic metacarpal and metacarpal-like hand deformity in adult patients. Methods: Multi-database searching with index and free text terms, duplicate standardised screening and extraction, and quality assessment was performed. The inclusion and exclusion criteria were prespecified. We included any randomised controlled trials, cohort studies, case-control studies, as well as interrupted time series, before and after intervention studies. Results: Screening of 548 articles yielded 20 studies eligible that included 19 retrospective observational studies and one before and after intervention study. A total of 171 patients underwent 274 toe transfers for metacarpal and metacarpal-like hand deformity. No study compared toe-transfer to a control group or to a prosthesis. The before and after intervention study demonstrated significant improvement in activities of daily living, work, aesthetics and satisfaction. Additionally, no significant donor site morbidity occurred in the heterogenous sample. Outcomes from remaining studies at risk of bias suggest that those with a lesser severity of injury and at least two toe transfers score higher in functional tests and scoring systems. Conclusions: There is limited confidence in the effectiveness of toe transfer for metacarpal and metacarpal-like hand deformity. The available evidence indicates that toe transfer(s) may restore acceptable function permitting activities of daily living, return to original or sedentary occupation and affords satisfaction. Level of Evidence: Level III (Therapeutic).

Bilateral Metacarpal Hands: Reconstruction With 6 Toe Transfers

Background: Bilateral metacarpal hand injuries are extremely rare, but probably represent the most difficult reconstructive challenge in hand surgery. Methods: We discuss the various options for metacarpal hand reconstruction, including the Krukenberg procedure, bionic prostheses, multiple toe-to-hand transfers, and possibly hand transplantation, and present the long-term functional outcomes, gait analysis, and psychological evaluation after a 4-stage reconstruction of bilateral metacarpal hands in a child using 6 toe-to-hand transfers-bilateral great toe transfers to reconstruct both thumbs and bilateral combined second-third monobloc transfers to reconstruct 2 fingers in each hand. Results: Reconstruction of bilateral metacarpal hands with 6 toe transfers yielded excellent functional results and patient satisfaction. Conclusions: Bilateral metacarpal hand injuries result in a devastating functional deficit and a major psychological impact. Multiple toe transfers (4, 5, or 6) provide an excellent reconstructive outcome with acceptable donor site morbidity.

Review of catastrophic hand diagnosis over 15 years in a tertiary hospital: do we make proper use of the term?

OBJECTIVE

To describe the characteristics of patients diagnosed with 'catastrophic hand' by the plastic surgery department in a tertiary hospital in the period between 2000-2015, analyse the evolution of the use of the term 'catastrophic hand' and conduct a review of the literature with a view to proposing the optimal definition for said expression.

MATERIAL AND METHOD

We conducted a descriptive and retrospective study of patients diagnosed with 'catastrophic hand' who required hospital care by the plastic surgery department of a tertiary hospital in the period between 2000-2015. We conducted a literature review on the use of the term 'catastrophic hand' and we applied the classifications proposed in the publications consulted to our results.

RESULTS

The number of 'catastrophic hand' diagnoses was 133. We observed a downward trend in the use of the term over the years. Applying classifications based on the impossibility of recovery of an acceptable hand (presence of three long fingers and thumb) by reconstructive procedures, only 9 out of 133 patients could be considered to have 'catastrophic hands', constituting 6.7% of the total cases.

DISCUSSION

The term 'catastrophic hand' has different meanings, and this generates ambiguity. The use of a classification based on the possibility of obtaining an acceptable hand diminishes its use and improves the approach for such injuries.

CONCLUSION

We advocate limiting the use of 'catastrophic hand' to cases that meet criteria of 'mutilated hand' and 'metacarpal hand' to avoid indiscriminate use of the term and optimise therapeutic management.

The Utility of the Knotless Suture Fixation for Bilateral Second Toe Transplantation in Traumatic Multiple-Digit Amputation

Toe-to-hand transfer is a useful reconstruction method after finger amputation. We report a case of multiple-digit amputation, reconstructed with bilateral second-toe transfer. In this study, we used a knotless suture fixation system (ZipTight™; Arthrex Inc., FL, USA) which effectively closed the wound and reduce the amount of dead space. Both second-toe transplantations survived. The feet were asymptomatic with good cosmetic outcomes. Although the reconstructed digits had limited range of motion, the patient was able to return to work. Knotless suture fixation system may be one of the effective methods for closing the donor site wound in second-toe transplantations.

Metacarpal-Like Hand: Classification and Treatment Guidelines for Microsurgical Reconstruction with Toe Transplantation

The metacarpal-like hand is a severe hand injury, never addressed before. It describes a hand that has lost a significant degree of prehension through a wide array of amputations, involving all digits proximal to the functional length except in one finger or in two digits, including the thumb. The thumb condition can be used to differentiate between two types. In type I, the thumb is intact or amputated at or distal to the interphalangeal joint (functional length); therefore, the reconstruction is focused mainly on fingers. In type II, the thumb is amputated proximal to the interphalangeal joint; therefore, the reconstruction is focused on both the thumb and fingers. Thumb amputation level, integrity of the first basal joint, and functionality of the thenar muscles can be used to subdivide type II. Functional reconstruction should consider the patient's desire and vocational needs. The finger left with adequate functional length is assessed for its location, level of amputation, and joint motion, especially the proximal interphalangeal joint. The goal is to use the reliable techniques of toe-to-hand surgery to reconstruct more opposable units, at least two fingers, whether adjacent to each other or not, and the thumb, when needed, to achieve a functionally and aesthetically better hand instead of a functionally adequate hand, with a more acceptable to ideally natural hand cascade. Strategic, individualized toe transfer(s) is the key element in fulfilling the goals of this operation whether single or multiple toes are transplanted.

The Biomechanical Impact of Digital Loss and Fusion Following Trauma: Setting the Patient up for Success

Surgeons managing mutilating hand injures are faced with difficult decisions between attempting to salvage remaining or injured digits or proceeding to amputation and fusion. Through application of a basic understanding of hand biomechanics, the surgeon may more accurately predict what motion and function can best be salvaged. This article provides an explanation of how amputation, fusion, and tendon loss can affect postoperative hand motion. The surgeon can use these concepts in planning the reconstruction or preparing the foundation for secondary reconstructive procedures to achieve the highest functional outcome for the patient.

Metacarpal-Like and Metacarpal Hand

The metacarpal-like and metacarpal hand injuries are devastating conditions that render the hand nonfunctional. Although the metacarpal hand is well-studied, the metacarpal-like hand is never addressed. The authors, using the same principles as in the classification and treatment of metacarpal hand, propose an easy to follow treatment algorithm for metacarpal-like hand injury to guide the reconstructive surgeon. For both injuries, microsurgical toe-to-hand transplantation can restore an acceptable level of function if done properly. Meticulous planning is essential for the toe-to-hand surgery to achieve its prime goal of stable tripod pinch with insignificant morbidity at the donor sites.

Recent Advances in Immediate Toe-to-Hand Transfer

Toe-to-hand transfer is the last option for definitive reconstruction of the hand when digits have been lost as a result of traumatic amputations, congenital anomalies, or tumor ablation. Immediate toe-to-hand transfer for the treatment of acute hand injuries is defined as an emergency operation performed when replantation is impossible or failed. The aim of this article is to propose the indications, advantages and disadvantages of immediate toe to hand transfer as well as to compare the overall results with elective cases.

The Indications for Toe Transfer after “Minor” Finger Injuries

Toe-to-hand transfer is widely considered to be unjustified for “minor” finger injuries. In this invited personal view article the indications for toe-to-hand transfer for finger amputation and neurocutaneous and major pulp defects are discussed, and a classification of multidigital injury that has both prognostic and decision-making value is presented. In the author's opinion a toe transfer should always be considered as an option when reconstructing “minor” finger injuries, as it can reproduce significant long-term benefit to the hand and the patient's sense of well being. The procedure should be carried out in the acute period, not only because it is technically easier and better for hand function, but above all because the surgeon can save structures that will be lost if the transfer is delayed.

Multiple-digit resurfacing using a thin latissimus dorsi perforator flap

Traumatic digit defects of high complexity and with inadequate local tissue represent challenging surgical problems. Recently, perforator flaps have been proposed for reconstructing large defects of the hand because of their thinness and pliability and minimal donor site morbidity. Here, we illustrate the use of thin latissimus dorsi perforator flaps for resurfacing multiple defects of distal digits. We describe the cases of seven patients with large defects, including digits, circumferential defects and multiple-digit defects, who underwent reconstruction with thin latissimus dorsi perforator flaps between January 2008 and March 2012. Single-digit resurfacing procedures were excluded. The mean age was 56.3 years and the mean flap size was 160.4 cm(2). All the flaps survived completely. Two patients had minor complications including partial flap loss and scar contracture. The mean follow-up period was 11.7 months. The ideal flap for digit resurfacing should be thin and amenable to moulding, have a long pedicle for microanastomosis and have minimal donor site morbidity. Thin flaps can be harvested by excluding the deep adipose layer, and their high pliability enables resurfacing without multiple debulking procedures. The latissimus dorsi perforator flap may be the best flap for reconstructing complex defects of the digits, such as large, multiple-digit or circumferential defects, which require complete wrapping of volar and dorsal surfaces.

Digital pulp reconstruction with free neurovascular toe flaps

Finger pulp defects are commonly encountered in clinical settings and their treatment remains a consistent challenge for plastic and hand surgeons. Reconstruction should restore, as much as possible, the contour of the pulp as well as discriminating sensibility. Following the prime reconstructive principle of replacing "like with like," the free neurovascular toe pulp flap seems to be the optimal choice for digital pulp reconstruction because of the natural similarity of the digital pulp both anatomically and physically. However, after about 30 years of experience with this procedure, it is still controversial because it is technically demanding, involves donor site morbidity, and its reliability is questionable. With other small free flaps available, the application of this flap has been challenged and reconsidered. In this review we specifically focus on the reconstruction of soft tissue defects of digital pulp using the free neurovascular toe flap, aiming to investigate its advantages and drawbacks and obtain a comprehensive understanding of this procedure. The latest reconstruction concerns and technical refinements are also discussed.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article.

The functional results of post-traumatic metacarpal hand reconstruction with microvascular toe transfers

The aim of this retrospective study was to evaluate the functional results of grip reconstruction after metacarpal amputation with microvascular toe transfer or transfers. The Sollerman hand function test and modified Tamai score were determined. Additionally, secondary objective outcomes were measured. As subjective outcomes, the patients were asked about pain, satisfaction, sensibility and activities of daily living (ADL). Complications and secondary operations were also recorded. An average of 12 years 5 months (range 11-270 months) follow-up of 8 patients (11 transfers) is presented. Sollerman hand function test averaged 54, range 36-73. The modified Tamai score averaged 63, range 54-70. All except one patient were either satisfied or highly satisfied. Patients' perception of function in terms of ADL was generally good (average 26 out of 44) with many activities causing no difficulty or only slight difficulty. The study showed that it is possible to reconstruct a reasonable grip using microvascular toe transfers.

Extra-Anatomic Microvascular Second Toe Transfer for Creation of a Helper Hand – a Long-Term Follow-Up

Mutilating hand injuries can significantly alter a patient's life. Return to work and daily activities remain the ultimate goal. A case report and long-term follow-up of a patient who caught his hand in a generator fan at work is presented. He sustained an injury that left him with a wrist and metacarpal stump. When prostheses failed, an extra-anatomic second toe transfer was used to produce a functional distal extremity. This transfer allowed the patient to return to his job and was surprisingly durable, resulting in a useful helper hand for 15 years.

Split second- and third-toe transplantation in mutilating-hand-injury reconstruction

Although bilateral second-toe transplantation has offered a satisfactory solution for multiple toe transplantation when the neighboring amputation stumps present an intact web space, exceptions exist. To provide an alternative and adapt the experience from the established methods, we propose split second- and third-toe transplantation in a 1-stage hand-function reconstruction. Three male patients underwent 4 split second- and third-toe transplantations for fingers amputated distal to the preserved or recreated web space. The average age was 22 years old, and all patients were reconstructed secondarily. No failure of transplantation occurred. All patients achieved restored hand functions for daily and occupational activities. In situations in which multiple lesser toe transplantations are required and harvesting toes from the bilateral foot may be needed, a split second- and third-toe transplantation with a healthy contralateral foot for allowing another toe transfer proves to have a satisfactory functional result and affords an opportunity for simultaneous or staged great toe transplantation.

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.

Isolated third-toe transfer: indications, technique, and reliability

BACKGROUND

Isolated third-toe transfer is a versatile and safe technique when indicated.

METHODS

Between January of 1984 and January of 2003, 37 isolated third-toe transfers were performed in 31 patients.

RESULTS

Only one partial loss was noted among 37 transfers. There were 24 male and seven female patients, with an average age of 27.4 years (range, 7 to 43 years). Twenty-five patients received additional toe transfers. Secondary surgery was performed in 17 toes of 15 patients to improve the functional and cosmetic results. Patients were followed for 2 to 180 months (average, 36 months) and no significant donor-site morbidity was seen.

CONCLUSIONS

Basically, the indications for isolated third-toe transfer are evaluated in two groups. Third-toe transfer is absolutely indicated when it is necessary for restoring basic hand functions in multiple-finger amputations. It is indicated because both second toes are transferred or the remaining second toe is adjacent to the previously transferred great toe. The other absolute indication is the unavailability of second toes because of trauma or deformity. Third-toe transfer is indicated relatively if it is used for additional reconstruction when basic hand functions are regained or already exist. Another relative indication is its better size match for proposed reconstruction. Second and third dorsal and plantar metatarsal arteries can be used as the pedicle artery for third toe-transfer; however, if second-toe transfer has already been performed or is planned, the third plantar or dorsal metatarsal artery should be used. Isolated third-toe transfer is a useful and reliable technique, especially in multiple-finger amputation reconstruction.

Overcoming soft-tissue deficiency in toe-to-hand transfer using a dorsalis pedis fasciosubcutaneous toe free flap: Surgical technique

Reconstruction of combined finger and soft-tissue defects poses a technical surgical challenge. We present our experience with a hybrid flap: the dorsalis pedis fasciosubcutaneous-toe free flap. In a single stage, this flap solves the problem of medium-sized defects associated with digit losses in the hand. Donor-site morbidity has been minimal.

The multiple monoblock toe-to-hand transfer in digital reconstruction. a report of ten cases

Ten hands with multiple traumatic finger amputations or congenital agenesis underwent reconstruction by monoblock transfer of multiple toes. Eight patients underwent monoblock transfer of the great and second toes, one patient received the great toe and the metatarsophalangeal joint from the second toe with the same vascular pedicle, and another patient the great, second and third toes as a block. Only part of the great toe was ever taken, while the second toe was totally or partially taken. The surgical technique and the outcome are detailed in this work, with a mean postoperative follow-up of 6 years.

Immediate Toe-to-Hand Transfer in Acute Hand Injuries: Overall Results, Compared with Results for Elective Cases

In the past 5 years, 25 mutilated digits were reconstructed with immediate toe-to-hand transfers after acute hand injuries, for 21 patients. The overall results of the immediate toe-to-hand transfers were evaluated and compared with the results of 65 elective procedures performed during the same period by the same surgeon. There were 15 cases of great toe-to-hand transfer for thumb reconstruction, two cases of second toe transfer for index finger reconstruction, and four cases of simultaneous two-toe transfer for reconstruction of multiple-digit amputations. Two cases (two of 25 cases, 8 percent) were successfully salvaged with emergency reexploration. The incidences of emergency reexploration and postoperative infection were not significantly different from those for elective toe-to-hand transfer cases. The duration of industrial insurance coverage was much shorter than for elective cases, averaging 225 days (p < 0.001). Approximately 44 percent of the patients maintained their original jobs after immediate toe-to-hand transfer. The subjective satisfaction self-assessment scores of aesthetic appearance and function for the newly reconstructed thumb averaged 80 and 88 (of a total score of 100), respectively. Although satisfaction was lower than for elective reconstruction (p < 0.001), it was higher than for reconstruction of other digits. The donor-site appearance after great toe harvesting was mostly unsatisfactory. Immediate toe-to-hand transfer provides many advantages over the elective procedure in acute hand injuries, including single-stage reconstruction, shortened convalescence, early return to work, and socioeconomic efficiency. Because there were no significant differences in the success rates, frequencies of complications, or ultimate functional results, immediate toe-to-hand transfer is a safe and reliable procedure that is indicated for specific cases of acute digital amputation.

Minimizing impairment in laborers with finger losses distal to the proximal interphalangeal joint by second toe transfer

Traditionally, toe-to-hand transfers have been reserved for thumb amputations or for use after severe mutilating injuries. The authors report their experience with the use of second toe-for-finger amputations with preserved or reconstructible proximal interphalangeal joints in manual workers. The aim of the procedure was to reduce impairment and to upgrade the hand from a functional and cosmetic standpoint. Fifteen second-toe wrap-around or variations were carried out on 11 adults (18 to 41 years old). Four patients with two or more finger amputations received two sequential second toes; four patients with two finger amputations received one toe; and each of three patients with single-digit amputation received a single toe. All but one amputation were performed less than 3 weeks after the accident. All toes survived. Range of motion at the native proximal interphalangeal joint was more than 90 percent in all patients but one; however, it was minimal at the transplanted joints. Patient satisfaction was high from a cosmetic and functional standpoint. Ten of 11 laborers resumed their previous activity. On the basis of this experience, a classification with aesthetic and functional implications is proposed to help in the decision-making process when dealing with multidigital injuries. It is concluded that second-toe transfer is an excellent choice for finger amputation distal to the proximal interphalangeal joint in laborers. Its prime indication is for amputations of two fingers where at least one toe should be transferred, as required, to achieve an "acceptable hand" (three-fingered hand). Early transfer allows salvage of critical structures from the damaged finger, such as joints, tendons, and bone, that otherwise would be lost. Early transplantation is highly recommended.

Two-stage reconstruction of four-digit amputation: distal ulnar artery flap and combined second- and third-toe transfer

We report a case of combined two toe transfer after distal ulnar artery fasciocutaneous flap in a 10-year-old boy who has four-digit amputation. Four years after the operation, satisfactory results were obtained both functionally and cosmetically.

Outcomes after mutilating hand injuries: review of the literature and recommendations for assessment

The functional outcome of a mutilating hand injury cannot be fully assessed at the time of injury alone. The measure of functional outcome must incorporate the evaluation and severity of the initial injury and the subsequent reconstructive surgeries. The complexity of the hand deserves no less. Restoration of prehensile function is the top priority in reconstruction following mutilating hand injuries, and assessment of outcome should address this goal. Flaps and specialized tissue grafts can restore architecture and balance in the hand. One can reconstruct a thumb and fingers with the big toe and smaller toes to give a functional sensate grip. The assessment of functional outcome should include not only objective measures but also subjective questionnaires that focus on issues most relevant to the patient. The use of questionnaires that have been shown to be valid, reliable, consistent, responsive, and sensitive allows the most meaningful conclusions about and comparisons between treatments. Perhaps because of the unique challenges presented by mutilating hand injuries, a new instrument, specific to mutilating hand injury, may provide the most beneficial information to guide treatment and assess outcome.

Biomechanics and hand trauma: what you need

Mutilating hand trauma presents the surgeon with many reconstructive challenges. This article establishes some biomechanical guidelines to help the surgeon evaluate the hand trauma patient. Through a basic understanding of hand biomechanics, the surgeon may access more accurately what motion and function can best be salvaged. By understanding how amputation, fusion, and tendon loss impact on postoperative hand motion, the surgeon can better focus his or her reconstructive efforts to achieve the highest functional outcome for the patient.

A long-term study of ring finger transfer in the reconstruction of transmetacarpal amputations

Restoration of adequate function in patients with metacarpal hands is a major challenge. In 1984, we presented a technique in which the contralateral uninjured ring finger was transferred by microvascular techniques to restore the dual hand functions of pinch and palmar grips. This was performed in combination with thumb reconstruction when necessary. The original 5 patients described in 1984, as well as 2 later cases, were reviewed for a long-term follow-up study (average, 19 y; range, 8-25 y). The average age of the patients at follow-up evaluation was 44 years (range, 13-73 y). Range of motion, grip span, sensibility, and grip strengths were measured. The Disabilities of the Arm, Shoulder, and Hand outcome measure was used to evaluate disability. The data show persistent good function with improving sensibility over the years. The ring finger transfer in reconstruction of transmetacarpal amputation has proven to be a good technique with an overall satisfactory outcome, especially in its ability to restore some capacity for palmar grip, a function that has hitherto been unattainable by other means.

Modified "on-top-plasty" technique for restoring length to amputation stumps

Five patients were successfully treated with a modified "on-top-plasty" technique, in which a finger stump is lengthened by transfer of an adjacent amputation stump with a reverse blood flow fingerstump. This technique can be performed in the acute phase or as a secondary procedure. A conventional on-top-plasty can be performed by transfer of a partially amputated index or ring finger to the "top" of the proximal phalanx of an amputated middle finger. Alternatively, the transferred part may be used in an intercalated fashion to reconstruct the middle phalanx, using a prosthesis to reconstruct the proximal interphalangeal joint. The results, complications and disadvantages of the technique are reported. We propose this procedure for the reconstruction of the middle ring finger when a free microneurovascular toe-to-hand transfer is contraindicated or refused by the patient.

Double-toe transplantation following temporary insertion of a block of silicone for reconstruction of a traumatic metacarpal defect

The treatment of the mutilated hand with more than one digit missing and a metacarpal defect is challenging. We used double-toe transfer after temporary insertion of a block of silicone to fill the bony defect.

Microvascular hand surgery-transplants and replants-over the past 25 years

Two hundred eighty articles related to microvascular transplants and replants published in The Journal of Hand Surgery over the past 25 years were reviewed. Every facet of microsurgery was covered. One hundred seventy-one articles are referenced and discussed under the following major categories: microvascular transplants, replants, nerve grafts, vein grafts, cold intolerance, vasospasm, monitoring, immediate reconstruction, and historical. Contributions were received from 37 countries and 175 authors or groups of authors.

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.

Free toe pulp transfer for digital reconstruction after high-pressure injection injury

We report two cases of high-pressure injection injuries to the fingertip in which free toe pulp flaps were used to resurface the palmar surface of the finger following extensive wound debridement. There was good return of sensibility and, because of the high durability of the donor skin, both patients regained good functional use of the injured digits and returned to heavy manual work. There was minimal associated morbidity of the donor sites. The free toe pulp flap represents an excellent alternative for resurfacing the digit with a large residual skin defect after high-pressure injection injury.

Double second toe transfer in congenital hand anomalies

A series of 14 patients with congenital hand anomalies who received staged double second toe transfers to the same hand for restoration of function or form were reviewed retrospectively. There were three children with constriction ring syndrome, two with symbrachydactyly and nine with transverse absence (failure of formation). There were different indications, technical difficulties and results with the various anomalies. All transferred toes were mobile and sensate, and were reported to be of benefit in both function and appearance. However, secondary surgical procedures were required in all patients.

Single versus double arterial anastomoses in combined second- and third-toe transplantation

Combined second and third toe transplantation is one good option for reconstruction of multiple digit amputation. However, the use of one or two arteries for pedicle anastomoses, which may influence the vascular complication and success rate, has never been addressed in the literature. This study includes a retrospective review of 57 combined second and third toe transplantation in 54 patients performed from February of 1983 through December of 1996. Group I, composed of 41 transplantations, underwent one arterial anastomosis, and group II, composed of 16 transplantations, underwent double arterial anastomoses during surgery if there were two recipient arteries available or whenever the second and third toes showed inadequate blood perfusion after one arterial anastomosis. In group I, 10 transplantations (24.4 percent) required re-exploration with a success rate of 92.7 percent (38 out of 41 transplantations). In group II, only one transplantation (6.2 percent) required re-exploration with successful flap salvage. The success rate was 100 percent for group II. Because the re-exploration and success rates between groups I and II were not statistically significant according to two-tailed Fisher's exact test, the combined second and third toe transplantation is a reliable procedure using either single or double arterial anastomoses.

Composite osteoarthrotenocutaneous free flap from the foot for reconstruction of an unusual hand wound

A case of a single-stage reconstruction of the left hand of a 32-year-old right-handed construction worker with a shotgun wound by means of a composite osteoarthrotenocutaneous free flap from the foot is presented. The tissue loss caused by the injury included the cutaneous coverage of the dorsum of the left hand, extensor tendons of the second, third, fourth and fifth digits, metacarpals of the same fingers, and the second and third metacarpophalangeal joints. After 8 years of evolution, we have been able to verify a valuable degree of functional capability of the reconstructed hand.

Metacarpal hand: classification and guidelines for microsurgical reconstruction with toe transfers

Metacarpal hand refers to the hand that has lost its prehensile ability through amputation of all fingers with or without amputation of the thumb. Functional restoration can be achieved by a wide variety of microvascular toe transfer techniques. When deciding which procedure should be used, careful consideration must be given to the level of amputation of the fingers as well as the functional status of the remaining thumb. In this article we propose a classification for the various patterns of the metacarpal hand along with guidelines for selection of the proper toe transfer procedure.

Current concepts of toe-to-hand transfer: surgery and rehabilitation

Optimal functional recovery after toe-to-hand transfer depends on skillful surgery as well as aggressive motor and sensory rehabilitation. The patient should be well motivated and willing to incorporate the involved hand in daily living and carry out the rehabilitation program on a daily basis. This article presents the current recommendations for the different toe-to-hand transfers and their postoperative rehabilitation programs.

Recovery of sensation and somatosensory evoked potentials following toe-to-digit transplantation in man

Recovery of digital nerve function in 21 patients with toe-to-digit transplantation was evaluated by clinical sensory tests and somatosensory evoked potentials (SEPs) to median and digital nerve stimulation. The mean interval between injury and surgery was 7 months, and that between surgery and study was 31 months. The transplanted toes achieved a satisfactory but incomplete recovery in temperature (warm and cold), pinprick, touch, vibration, and two-point discrimination in that order. The overall sensory status of the transplanted toes appeared to be closer to normal toes than to normal fingers. In SEPs from the transplanted side, median N9, N13, and N20 components had normal latency but reduced amplitude, whereas digital N9 component was usually absent, but N13 and N20 components had prolonged latency and reduced amplitude. Transplantation performed within 1 month after injury prevented amplitude reduction in median SEPs and latency prolongation in digital SEPs. The SEP data suggest that timing of surgery was critical in preventing retrograde effect on the median nerve, and that recovery of digital nerve function was incomplete correlating with clinical sensory findings.

Toe-to-finger transfer combined with wrap-around flap: a new technique for four-finger amputation

A surgical technique for reconstruction of four-finger amputation, toe-to-finger transfer combined with wrap-around flap procedure, is described. Opposable ulnar fingers, reconstructed using the second and third toe, provide sufficient grip function. The long finger, reconstructed with the wrap-around flap using the lateral aspect of the great toe, provides pinch function. Improving the hand function is worthwhile despite morbidity from losing two toes.

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.

Multiple microsurgical toe-to-hand transfer in the reconstruction of the severely mutilated hand. A series of fifty-nine cases

The severely mutilated hand is defined as the hand which has lost opposable digit function either through: a) The amputation of all four fingers proximal to the PIP joint or b) The loss of the thumb proximal to the IP joint combined with the loss of at least three fingers proximal to the PIP joint. We have outlined guidelines for the restoration of useful function and appearance to such hands utilising a variety of microsurgical toe-to-hand transfers. Specific points regarding postoperative management have been made.