Free vascularized small joint transfer to the hand

Vascularized Origami Medial Femoral Condyle Flap for Finger Joint Reconstruction

SUMMARY

Total finger joint reconstruction is challenging. Vascularized toe joint transfer is currently used for reconstruction, but it is difficult to perform, fails to achieve maximal joint flexibility, and is associated with donor-site complications. As an alternative, the authors developed a vascularized medial femoral condyle flap technique, wherein the vascularized corticoperiosteum is shaped via origami, with the donor tissue folded to fit the recipient site. In this article, the authors describe the use of this method for reconstruction of interphalangeal and metacarpophalangeal joints with a reduced range of motion. The mean age of the patients (three men and four women) was 51 years (range, 36 to 68 years), and the mean follow-up period was 3 years 1 month (range, 4 months to 5 years). In the reconstructed joints, the mean range of motion; Disabilities of the Arm, Shoulder, and Hand score; and pinch strength of the unaffected side were 55 degrees (range, 24 to 90 degrees), 2.3 (range, 0 to 6), and 98% (range, 70% to 38%), respectively. No donor-site morbidities were observed. Radiography and computed tomography scans revealed joint-like grafted tissue remodeling. The study findings suggest that the origami medial femoral condyle flap is useful for functional finger joint reconstruction. The procedure requires fabrication before grafting, but tissue harvest is relatively easy.

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.

Silicone and Pyrocarbon Artificial Finger Joints

Artificial finger joint design has been developed through different stages through the past. PIP (proximal interphalangeal) and MCP (metacarpophalangeal) artificial finger joints have come to replace the amputation and arthrodesis options; although, these artificial joints are still facing challenges related to reactive tissues, reduced range of motion, and flexion and extension deficits. Swanson silicone artificial finger joints are still common due to the physician's preferability of silicone with the dorsal approach during operation. Nevertheless, other artificial finger joints such as the pyrocarbon implant arthroplasty have also drawn the interests of practitioners. Artificial finger joint has been classified under three major categories which are constrained, unconstrained, and linked design. There are also challenges such as concerns of infections and articular cartilage necrosis associated with attempted retention of vascularity. In addition, one of the main challenges facing the silicone artificial finger joints is the fracture occurring at the distal stem with the hinge. The aim of this paper is to review the different artificial finger joints in one paper as there are few old review papers about them. Further studies need to be done to develop the design and materials of the pyrocarbon and silicone implants to increase the range of motion associated with them and the fatigue life of the silicone implants.

Comparative meta-analysis of pyrocarbon and silicone for joint replacement surgery

OBJECTIVE

To investigate the efficacy and complications that might be associated with pyrocarbon compared with silicone in patients undergoing joint replacement surgery.

METHODS

The full-text papers about the clinical efficacy of pyrocarbon and silicone were retrieved from multiple databases. Review Manager version 5.0 was adopted for meta-analysis and analyses of sensitivity and bias.

RESULTS

Ultimately, we studied 232 patients across eight studies that met the eligibility criteria. The meta-analysis suggested a significant difference between the pyrocarbon and silicone groups in terms of the Disabilities of the Arm, Shoulder, and Hand (DASH) score (standard mean difference (SMD) = 1.48; 95% CI [0.97, 1.99]; P = .009; P for Heterogeneity <0.00001; I = 63%); Visual Analogue Score (VAS) (SMD = 1.68; 95% CI [1.36, 1.99]; P < .00001; P for heterogeneity = 0.01; I = 61%), and the abnormal radiolucent line (RR = 6.66; 95% CI [3.19, 13.89]; P < .00001; P for heterogeneity = 0.87, I = 0%); and ossification development (RR = 0.90; 95% CI [0.56, 1.44], P = .66; P for heterogeneity = 0.94, I = 0%).

CONCLUSION

This study showed that pyrocarbon might be an efficient material compared with silicone for joint replacement surgery, but resulted in poorer functional and pain outcomes compared with silicone.

Use of a Costal Osteochondral Graft for Reconstruction of a Proximal Phalanx Head with a Comminuted Fracture of the Proximal Interphalangeal Joint

We report the use of costal osteochondral grafting with a pins and rubbers traction system (PRTS) for treatment of a complex cartilage defect of the proximal interphalangeal (PIP) joint in a 41-year-old male carpenter who had inadvertently incompletely severed his finger with a power saw. The skin laceration extended to the dorsal aspect of his ring finger and resulted in incomplete loss of the ulnar condyle and comminution of the radial condyle of the proximal phalanx of the PIP joint. The diagnosis was intra-articular PIP joint open fracture of the left ring finger with a 60% defect of the proximal phalanx joint surface. Three weeks after the injury, PIP joint reconstruction was performed with a costal osteochondral graft harvested at the osteochondral junction of the fifth rib. The volar side of the proximal phalanx cortex and the condyles of the proximal phalanx on each side, which included the origin of the collateral ligaments, were preserved. The graft was shaped to match the defect, and biplane fixation with three miniscrews was subsequently performed. Last, a PRTS was attached. At 6 months postoperatively, the patient returned to his job; at 12 months postoperatively, the joint was stable and free of pain. This technique enabled preservation of joint stabilizers and rigid fixation of the graft, resulting in a good outcome. Our modified costal osteochondral graft with a PRTS is useful for severe intra-articular fractures of the PIP joint and should be considered before salvage procedures.

Our surgical technique to treat premature growth plate closure 7 years after toe-to-thumb transfer. A case report

In children, traumatic distal amputations of the thumb can be treated by partial first toe transfer. Growth is preserved by conserving a portion of the growth plate in the hallux distal phalanx. In the patient featured here, 7 years after such a distal thumb reconstruction, bone bridge resection was needed to restart growth and correct clinodactyly. When this patient was reviewed 4 years later, the thumb's longitudinal growth had been restored and continued.

Vascularized transfer of two coherent toe joints in simultaneously reconstructing MCP and PIP of a mutilated finger

BACKGROUND

The reconstruction of metacarpal- and interphalangeal joints after severe hand injuries has been proven to be challenging. Commonly used procedures like arthrodesis, amputation or ray resection of the finger compromise the functionality of the injured finger. Especially for young patients, the restoration of all functions of the fingers is a priority. Local tissue transfers for finger joint reconstructions is not an option due to inacceptable donor site morbidity; microsurgical tissue transfers in terms of free toe joint transfers have proven to be a valuable method.

METHODS

We present the case of a patient who suffered an excessive injury from a circular saw to his dominant hand. The MCP Joints of D2-D4 were fully destroyed, along with the PIP joint of a subtotally amputated D4. Arteries, nerves and tendons could be coapted directly, while primarily reconstructing of the finger joints was impossible. To ensure a possible regain of full functionality, two coherent joints, the MTP and the PIP of one toe, were transferred to the ring finger as a single transplant, reconstructing the MCP and the PIP joints of the injured finger in a one step procedure. Additionally the MCP joint of the D2 was reconstructed by the use of a free PIP-joint transfer, further the MCP joint of the D3 was replaced by an MCP endoprosthesis.

RESULTS

After a follow up of 3 years the patient displayed full function of his dominant hand including sensitivity, and has gone back to manual work without limitations. The result was cosmetically acceptable and the donor site defect was easily being tolerated by the patient who is playing soccer in the regional soccer league.

CONCLUSION

Free double toe joint transfer has been proven feasible in this patient. While transferring a single toe joint to reconstruct a finger joint is a well-established method, our review of the latest literature showed no case of a free transfer of two coherent joints and three transplanted joints in one hand. The applied microsurgical technique should be considered by microsurgically trained hand surgeons for the treatment of comparable severe hand injuries. In comparison to the most common procedures described for the repair and reconstruction of severely injured finger joints this method showed superior results.

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.

Fourteen-year results of a reversed vascularized second metatarsophalangeal joint transfer: a case report

We report a case of free vascularized, second-toe metatarsophalangeal joint transfer in a 34-year-old manual laborer. The metatarsophalangeal joint of the left second toe was transferred to the metacarpophalangeal joint of the right ring finger in a reversed fashion. Fourteen years after surgery the transferred joint is painless and stable and flexion is 80 degrees with extension lag of 52 degrees without arthritic changes on radiographs.

Long-term results of free vascularized second toe joint transfers to finger proximal interphalangeal joints

PURPOSE

To review the long-term clinical results of free vascularized second toe joint transfers for severely damaged finger proximal interphalangeal (PIP) joints.

METHODS

Eleven joints in ten patients (1 woman, 9 men) were reviewed between 10 and 22 years after surgery. The average patient age at the time of the surgery was 32 years. Patients were evaluated at a mean follow-up time of 15 years; evaluation included range of motion of the transferred PIP joints and the remaining healthy second toe PIP joints, grip strength, finger and toe pain, finger function, gait disturbance, patient satisfaction, and x-ray changes.

RESULTS

The mean active range of motion was 47 degrees that lacks 41 degrees extension and flexes to 88 degrees. The mean grip strength was more than 80% that of the nonaffected hand, and no finger pain or gait disturbances were reported. All patients had some extension lag and flexion contractures but most were satisfied with the clinical and functional results of surgery. In all joints, the joint spaces were preserved, although 1 patient had arthritis and 3 had osteophytes.

CONCLUSIONS

It is important to prevent extension lag and flexion contracture to get better results from free vascularized second toe joint transfers. The transferred toe PIP joint is durable.

Osteochondral reconstruction of a non-weight-bearing joint using a high-density porous polyethylene implant

Currently, there is no reliable reconstructive modality allowing anatomic resurfacing of traumatic digital osteochondral articular defects. The purpose of the present study is to demonstrate the utility of Medpor, a high-density porous polyethylene (HDPP) scaffold biomaterial that can (1) be readily contoured to fit any joint defect, (2) permit stable internal fixation, and (3) permit osteocyte and chondrocyte ingrowth and subsequent articular cartilage resurfacing necessary to restore joint congruity. HDPP has gained wide acceptance for use in craniofacial and skeletal reconstruction and augmentation. An avian non-weight-bearing joint model was designed to study the role of the HDPP implant in small joint reconstruction. An osteochondral defect was created with a 5-mm circular punch in the humeral articular surface of both glenohumeral joints of 32 adult White Leghorn chickens. In each animal, one defect was press-fitted with a correspondingly sized HDPP implant (HDPP implant group); the contralateral defect was filled with the original osteochondral plug (isograft group) or left unrepaired (control group). At 2 weeks, and 1, 3, and 6 months,joints from each group were harvested and evaluated. Over the 6-month study period, joints in the control group demonstrated healing with dense collagenous scar tissue leaving residual defects at the articular surfaces and significant degenerative disease of the glenohumeral joints radiographically. Joints in the isograft group demonstrated near-complete resorption with some preservation of the cartilaginous cap but overall depression of the articular surface and significant degenerative joint disease. Joints in the HDPP implant group demonstrated stable fixation by highly mineralized bony trabecular ingrowth, preservation of the articular contour of the humeral head, and no evidence of significant degenerative joint disease. These findings indicate a potential role for this high-density porous polyethylene implant in the reconstruction of small joint articular and osseous defects.

Single pedicle vascularized double joint transfer: anatomic study of two models

This study examined the anatomic structures that communicate between the tibial and fibular digital arteries of the second toe at the distal phalanx to identify a channel for retrograde blood flow from the dominant pedicle to the distal joint flap. We also assessed the feasibility of two models designed to mobilize toe joints to perform single pedicle vascularized double-joint transfer. The continuity of the vascular pathway in both models was demonstrated by microfil injection and angiographic study. The average mobile distance between the PIP joint and the MTP joint was 5.6 +/- 0.6 cm in model I and 5.1 +/- 0.4 cm in model II. The dissection and mobilizing procedures of the neurovascular pedicle are more complicated and extensive in model II than in model I, and the risk of jeopardizing vascularity of the distal joint flap is higher. Both models may be suitable to replace two adjacent metacarpophalangeal (MCP) joints in the hand or two nonadjacent MCP joints (excluding the thumb) separated by no more than one normal metacarpal.

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.

Vascularized Fibular Epiphyseal Transplantation for Limb Salvage Following Bone Tumour Excision

Vascularized fibular transplantation has found wide application for long bone reconstruction in both congenital and acquired defects. However, in children the growth of these transplants is limited and requires the epiphysis if it is to be substantial. Also, the reconstruction of a joint is best achieved with autologus hyaline cartilage. Vascularized fibular epiphyseal transplantation, thus, may play a role in limb salvage procedures in children to both preserve joint function and facilitate long bone growth. The present paper discusses the history of vascularized epiphyseal transplantation both in the laboratory and clinical realm. In discussing its advantages and associated problems, special emphasis is directed at the vascular factors, the endocrine environment, the innervation, mechanical stressors, the recipient site and the donor site. Two case examples are presented to demonstrate the technique, the results and the long term outcome.

Microarterial anatomy of the lesser toe proximal interphalangeal joints

Successful free tissue transfer requires detailed knowledge of the pertinent microvascular anatomy of the donor site. The lesser toe proximal interphalangeal joints are a source of vascularized autologous tissue. In 20 adult cadaver feet, the arterial anatomy of the second, third, and fourth toes was studied using colored latex and India ink injection. The second, third, and fourth dorsal metatarsal arteries produced small or absent dorsal digital arteries in 72.5% of distal dissections. The proper digital arteries were 0.93 to 1.37 cm in length. An additional 2.3 to 2.83 cm of length can be gained by use of the plantar metatarsal arteries if the dorsal metatarsal or dorsal digital arteries are inadequate. The diameter of the medial proper digital arteries (range, 1.2-1.26 mm) was larger than the lateral proper digital arteries (range, 0.66-0.99 mm). The proper digital arteries of the lesser toes provide the predominant arterial supply of the proximal interphalangeal joints through a system of transverse and longitudinal arches.

Epiphyseal plate transplantation: an historical review

Non-vascularized and vascularized transplantation of epiphyseal plate autografts have been performed both clinically and experimentally for over 100 years. However, the ultimate clinical goal of vascularized transplantation of epiphyseal plate allografts for paediatric extremity reconstruction remains elusive, due primarily to the lack of suitably nontoxic techniques to prevent graft rejection. We have summarized the published clinical and experimental investigations of vascularized epiphyseal plate transplantation, and organized the experiments and clinical operations into four main groups: (1) local vascular studies on unmanipulated epiphyseal plates, (2) studies of epiphyseal plate behaviour after orthotopic replantation, (3) studies of epiphyseal plate behaviour after heterotopic transplantation, and (4) studies of epiphyseal plate behaviour after allograft transplantation. Prior investigations into the non-vascularized transplantation of epiphyseal plate autografts and allografts are presented as background. These groups of studies serve as the building blocks for the more clinically applicable experimental investigations outlined in the final section of this review.

Bernard O'Brien: the microsurgical transfer of immature bone

Bernard O'Brien was one of the pioneers of vascularized epiphyseal plate transfer. His clear understanding of the wide array of potential applications for reconstructive microsurgery stimulated his interest in the transfer of growing long bones. Investigations have been carried out in his laboratory since the earliest days of skeletal free tissue transfers. This paper describes the work done with epiphyseal plate transfers in O'Brien's laboratory. Research from other centers is then reviewed. Finally, the experience with clinical application is described.

Free and island vascularized joint transfer for proximal interphalangeal reconstruction: a series of 27 cases

Twenty-seven vascularized joints were transferred in 26 patients for proximal interphalangeal joint reconstruction: 7 heterodigital island, 7 homodigital island (distal to proximal interphalangeal), 2 free heterodigital, and 11 free second toe proximal interphalangeal. With a mean follow-up period of 37 months, mean active range of motion of heterodigital island joint was 56 degrees (mean extensor lag, 21 degrees), excepting one failure ending with an arthrodesis. Four complications occurred in the homodigital island joint series: one sepsis, one nail dystrophy, one failed distal arthrodesis, and one bone abutment in flexion. Excluding the sepsis, mean active final range of motion was 52 degrees after a mean follow-up period of 18 months. The two free heterodigital joints had 80 degrees and 65 degrees of motion. The worst results occurred in the free second toe proximal interphalangeal joints transferred, with a mean active range of motion of 33 degrees (mean extension lag 39 degrees). The main advantages of these techniques are a compound tissue transfer, rapid bone healing, good lateral stability, growth potential, and long-term cartilage preservation.

Short-term response of epiphyseal plate cell populations following selective devascularization and microsurgical revascularization

The distal femoral epiphyseal plates of 21 8-week-old New Zealand white rabbits were totally or partially (nutrient artery only) devascularized, or devascularized and then microsurgically revascularized. Sacrifice was at 24, 48 or 72 hours postoperatively. The heights of the proliferative and hypertrophic zones of the epiphyseal plates operated upon were compared with the contralateral control epiphyseal plates for both the central and the peripheral regions of the epiphyseal plate. Neither extent of devascularization nor revascularization had a significant effect on the height of the proliferative zone of chondrocytes at any of the follow-up intervals. Selective devascularization of the nutrient artery led to a significant increase in height of the central region of the hypertrophic zone of chondrocytes at 48 and 72 hours. Microsurgical revascularization did not lead to a significant change in the height of either the central or the peripheral regions of the hypertrophic zone of chondrocytes at any of the follow-up intervals. This study is another 'building block' experiment toward vascularized epiphyseal plate transplantation in humans.

Microvascular second toe to finger transfer: a statistical analysis of 55 transfers

A series of 55 second toe to long finger transfers in 42 patients are reviewed. The mean age is 17 years. The mean follow-up is more than 4 years. Two-point discrimination averages 8 mm. The sensibility is influenced by age, amputation score, ischaemic time, number of arteries, level of amputation, mobility, compensation injury and sensory re-education. The mean mobility is 33 degrees of flexion with a mean extension lack of 34.5 degrees. The mobility is influenced by dominance, amputation score, ischaemic time, number of arteries, level of amputation and compensation injury. There are four failures (7.2%). This rate of complication is influenced by tobacco, age, number of arteries and level of vascular anastomosis.

Vascularized single toe joint transfer to the hand

We report a retrospective review of our series of thirty-one single joints harvested from the toe in twenty-six patients and transferred to the metacarpophalangeal or proximal interphalangeal joint of the finger. Twenty-six transfers were done in traumatic cases and five in congenital. Follow-up averaged 22.6 months. Average range of motion was from 17.1 degrees to 44.3 degrees, with an arc of 27.2 degrees. The congenital group had an average motion ranging from 14.4 degrees to 27.2 degrees and an arc of 12.8 degrees. The traumatic group's motion was from 17.6 degrees to 47.6 degrees and an arc of 30.0 degrees. Complication rates were significant, with fifty percent of the patients experiencing one or more complications. Although vascularized joint transfer is a demanding procedure, it provides a reasonable alternative to arthrodesis and with further refinement in technique may become a reliable treatment option.

Free vascularized whole joint transfer in children

Reconstruction of the traumatized finger joint with epiphyseal destruction has long been problematic. Since free vascularized whole joint transfer was introduced as a treatment for joint and epiphyseal destruction, this procedure has been selected as an alternative treatment because it may provide a growing epiphysis. We have reviewed our series of 19 joint transfers. Mean age at operation was 6.2 years (range 3 to 12). Average active range of motion was 31 degrees/61 degrees for the group with posttraumatic reconstruction (n = 12) and 21 degrees/43 degrees for the group with reconstruction of a congenital deformity (n = 7), with an overall average of 27 degrees/54 degrees. Average range of motion following transfer of an metatarsophalangeal (MTP) or metacarpophalangeal (MCP) joint to an MCP joint position was 39 degrees/75 degrees (n = 4); proximal interphalangeal (PIP) to PIP transfer was 22 degrees/39 degrees (n = 13); and PIP to MCP transfer was 38 degrees/51 degrees (n = 2). The proximal phalanges in MCP joints transferred to the MCP position grew an average of 7.0 mm, and the middle phalanges of joints transferred to the PIP position grew 4.3 mm. Almost normal growth was observed in all transferred joints except two that showed premature epiphyseal closure. Indications for this procedure and techniques to improve range of motion are described.

Free Vascularised Toe Joint Transfer for Reconstruction of the Metacarpo-Phalangeal Joint

Two single and two double free vascularised joint transfers from the foot to hand have been undertaken in four patients over a period of four years. All were to replace metacarpo-phalangeal joints in young patients in whom the use of prosthetic devices was considered unsuitable. All the transfers were successfully completed, but one failed late in the second post-operative week due to sepsis. The results of the remaining three transfers compare favourably with prosthetic arthroplasty and continue to improve. Donor site morbidity in the foot has been minimal and is reviewed.

Transfer of a composite island homodigital distal interphalangeal joint to replace the proximal interphalangeal joint. Technique and case report

The authors present an original technique of PIP joint reconstruction by an homo-digital island compound DIP joint transfer. The transfer consists of joint, capsule, volar plate, and ligaments. The distal joint is fused and the islanded joint interposed at the PIP level. In our clinical case, a flexion of 80 degrees was obtained with an extension lack of 15 degrees. This salvage procedure can be useful in selected well motivated patients. It provides rapid bone healing, good lateral stability, potential for growth in children, long term preservation of cartilage and acceptable range of motion.

Immediate silastic arthroplasty for non-salvageable intraarticular phalangeal fractures

Fourteen patients with open non-salvageable intraarticular fractures of the proximal interphalangeal joint or metacarpophalangeal joint, underwent immediate silastic arthroplasty using Swanson H.P. hinged implants. The patients' ages ranged from 14 to 49 years, with an average of 29 years. Time from surgery to final examination ranged from 4 months to 6 years, with an average of 26 months. The active range of motion obtained at the metacarpophalangeal joint arthroplasties ranged from 45 to 80 degrees, with an average of 60 degrees. The active range of motion obtained at the proximal interphalangeal joint arthroplasties ranged from 0 to 70 degrees, with an average of 29 degrees. Better results were generally obtained at the metacarpophalangeal level, and in those arthroplasties performed in non-amputated digits. There were no post-operative infections and all but one joint were stable.

Long-term follow-up of free vascularized joint transfers to the hand in children

Toe-to-hand vascularized joint transfers in four children were reviewed 6 to 8 years after operation (average, 6.6 years). Two children had vascularized metatarsophalangeal (MTP) joints. Both children have near normal active range of motion. The transferred epiphyses have provided a major contribution to digital growth. The other two children had second toe proximal interphalangeal (PIP) joints transferred to damaged hand joints. Active PIP joint extension has been disappointing, and the overall growth contribution of the transferred epiphysis has been small. We conclude that MTP to metacarpophalangeal vascularized joint transfer can provide painless, functional, stable motion, with near normal growth potential, and the usefulness of toe PIP to hand PIP joint transfer is limited by the inability to achieve good active extension and limited growth potential.

Experimental free vascularized epiphyseal transplants

Growth plates have been transferred both clinically and in experimental models since the end of the 19th century. Results have been unpredictable and frequently unsatisfactory due to postoperative ischemia. Modern microvascular techniques have minimized this problem and preservation of growth plate structure and function has been reported after replantation and free tissue transfers in children and immature animals. Experimental revascularized growth plate transplants were first reported in 1979. Viable orthotopic transfers are associated with rapid bony union, maintenance of radiological structure, and continued growth in length at near normal rates. Detailed studies have demonstrated a continuation of cell division, metabolic activities, and normal histology. Technetium bone scans have been a useful postoperative indicator of viability, and ischemic times of more than three hours can be tolerated. The behavior of heterotopic transplants has not yet been fully studied. Early attempts suggest that biomechanical problems may be troublesome.