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

The Medial Femoral Trochlea Osteochondral Flap for Scaphoid Reconstruction: A Systematic Review

BACKGROUND

The medial femoral trochlea flap has been used to resurface scaphoids with recalcitrant proximal pole fractures or avascular necrosis, providing vascularized osteochondral tissue with similar morphological characteristics. This article aims to review the contemporary literature on its use for scaphoid reconstruction.

METHODS

A systematic review of Embase, PubMed, Cochrane Central Register of Controlled Trials, and MEDLINE assessed the use of medial femoral trochlea flaps in scaphoids.

RESULTS

Eight studies were included, with 76 patients at a mean age of 26 years. Forty-three patients underwent clinical review, and 10 patients underwent radiographic evaluation, at a mean 23.3 months of follow-up. Flaps were generally performed for proximal pole fractures, avascular necrosis, nonunion, or failure of prior fixation; 94.4% of the flaps united. No marked change in sagittal plane motion was noted; reductions were seen in axial and coronal plane motion. The Disabilities of the Arm, Shoulder, and Hand scores improved from a mean of 25.2 to 11.5. Radiographic markers also improved. A total of 12.3% of patients had unplanned return to theater. Three patients required early revision for vascular thrombosis, and 1 patient suffered a volar carpal dislocation. Three patients underwent salvage procedures for ongoing pain.

CONCLUSIONS

Although technically demanding, promising early-term to medium-term results are noted with the use of medial femoral trochlea flaps in the scaphoid.

The Foot as a Donor Site for Reconstruction in the Hand

The foot contains a unique collection of tissue types that can be used in the reconstruction of the hand. Numerous reconstructive options have been presented, some of which have been adopted, such as modifications to procedures that have been described in the past or even newly developed options for hand reconstruction. It is possible to reconstruct missing fingers and other hand structures using tissues taken from the foot rather than removing healthy tissue from a hand that has already been injured. This makes it possible to avoid having healthy tissue removed from an injured hand.

Salvage of failed proximal interphalangeal arthroplasty with vascularised toe joint transfer: Report of two cases

Failed implants of the proximal interphalangeal joint may result in bone and soft tissue deficits and joint instability with limited reliable options for reconstruction besides an arthrodesis procedure. The purpose of this report is to illustrate the use of vascularized second toe joint for salvage of failed, multi-operated proximal interphalangeal joint in two active patients. Pre-existing scars are used to define the approach and choice of donor site. Flow through anastomosis was performed on the finger digital artery. At final follow-up, the transplanted joints achieved 80-90 degrees of motion and the patients were able to return to their desired level of activities. The procedure is a good alternative for the fit patient wanting to achieve a stable finger with preservation of motion in catastrophic failure of prosthetic proximal interphalangeal joint arthroplasty.

Forty-Two-Year Follow-Up After Heterodigital Vascularized Hemijoint Transfer: A Case Report

Heterodigital vascularized hemijoint transfer can theoretically produce a near normal joint by combining intact joint components from different fingers and maintaining the joint space over the long term. We present herein an extremely rare case of heterodigital vascularized hemijoint transfer with a 42-year follow-up, demonstrating the longevity of this joint reconstruction technique for the restoration of hand function. Our patient's outcome indicates that despite the gradual progression of osteoarthritic changes, good subjective results and maintenance of an active range of motion can be acquired even after a long period. Technical factors such as graft fixation and the congruity of the articular surface may influence the gradual degeneration of joint surfaces.

Vascularized Toe Proximal Interphalangeal Joint Transfer in Posttraumatic Fingers: Analysis of Prognostic Factors for Suboptimal Outcomes

Background

Posttraumatic finger osteoarthritis of the proximal interphalangeal joint (PIPJ) is a difficult problem. Over the past decade, we have reported several methods for improving the outcomes of vascularized toe joint transfer (VJT). In this study, we focused on determining poor prognostic factors which lead to a suboptimal outcome.

Methods

A consecutive series of patients with posttraumatic osteoarthritis of the PIPJ who received VJT between January 2008 and January 2021 were enrolled in this study. The senior surgeon (Y.-T.L.) performed the surgery in all cases. In this retrospective study, we reexamine the initial trauma-related soft tissue and bony structure injuries of the recipient finger, to assess the baseline tissue quality before VJT. The injuries were classified into five major categories according to their anatomic region. The functional outcome parameters (including range of motion, percentage of use, and extensor lag of the transferred PIPJ) were collected. Univariate and multivariate linear regression analyses were performed using the generalized estimated equation model to identify the correlation between the injury category involved and functional outcome.

Results

A total of 59 digits were enrolled. Our results revealed that the fingers with previous vascular injury that received revascularization procedures had relatively suboptimal functional outcomes. These fingers had a significantly lower percentage of use both before (β = -0.222, P = 0.006) and after (β = -0.177, P = 0.006) receiving secondary procedures to improve functional outcome.

Conclusions

Patients with prior revascularization surgery were associated with a poor functional outcome after VJT.

Toe-to-Finger Vascularized Joint Transfers for Proximal Interphalangeal Joint Reconstruction: A Systematic Review

Vascularized joint transfer (VJT) from the proximal interphalangeal joint (PIPJ) of the toe is an attractive reconstructive option in cases of nonsalvageable finger PIPJ but is limited by equivocal functional outcomes. This systematic review aims to provide an update on vascularized toe-to-finger PIPJ transfers, examining functional outcomes, complications, and the latest refinements in operative technique. A systematic review of the available literature was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies examining vascularized toe-to-finger PIPJ transfer for post-traumatic indications were included for analysis. Outcomes assessed included postoperative active range of motion, extension lag, and complications. Thirteen studies examining 210 VJTs were analyzed. Five VJTs experienced microsurgical failure giving an overall survival rate of 97.6%. Average postoperative PIPJ active range of motion (ROM) was 40.3° ± 12.9°, with an average extensor lag of 29° ± 10.5° and mean flexion of 68.9° ± 10.9°. For studies reporting complication outcomes, 59/162 complications were seen. No significant differences were seen between studies published prior to 2013 and after 2013 when comparing digital ROM (P = .123), flexion (P = .602), and extensor lag (P = .280). Studies using a reconstructive algorithm based on prior assessment of the donor toe central slip and recipient finger anatomy had significantly improved ROM outcomes (P = .013). Although VJT provides a reliable option for autologous reconstruction in posttraumatic joints, it is limited by impaired postoperative ROM. Careful assessment of the donor toe and recipient finger anatomy followed by systematic and meticulous reconstruction may lead to improved functional outcomes.

Perichondrial Arthroplasty Revisited: Technical Pearls

Articular cartilage damage has been a longstanding challenge in hand surgery. Because of its limited ability to heal on its own and its predictable impact on bone resulting in degenerative osteoarthritis, surgical intervention is often mandated, through arthrodesis or implant arthroplasty. In this article, we revisit the perichondrial arthroplasty, a two-stage joint resurfacing technique using autologous rib perichondrium. It is indicated for posttraumatic osteoarthritic changes with or without stiffness and deviation, rheumatoid arthritis, and congenital joint malformation and/or ankylosis. This long-lasting method allows for a functional, pain-free joint that avoids both the immobility of arthrodesis and the long-term complications associated with implants.

Use of a Box-cut Osteotomy Preserving Collateral Ligaments in Costal Osteochondral Graft Reconstruction of Proximal Interphalangeal Joint Cartilage Defects

We report two patients with reconstruction of osteochondral defects of the proximal interphalangeal joint (PIPJ) using a costal osteochondral graft (COG). A box-cut osteotomy was done at the end of the phalanx preserving the lateral cortices and the insertion of the collateral ligaments. A COG was harvested from the rib, moulded and press fit into the groove formed by the box-cut osteotomy. The COG was fixed with mini screws in the coronal plane (dorsal to palmar) and the fixation off-loaded with an external fixator. This technique maintained the collateral ligament in-situ and is useful in reconstruction of chondral defects of the PIPJ. Level of Evidence: Level V (Therapeutic).

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.

Reconstruction of digit planer injuries using component transfer of double second toes: A case report

The purpose of this report is to show that customized component second-toe transfers may improve functional and aesthetic outcomes following bone, soft tissue, and joint destruction of traumatically injured digits. A 22-year-old male sustained a planer injury resulting in loss of the distal volar soft tissues of the middle, ring, and small fingers, along with variable destruction of middle phalanges and distal interphalangeal joints. Simultaneous vascularized second-toe transfers were performed with customized joint and pulp reconstruction of middle and small fingers. The ring finger was salvaged using non-vascularized autologous bone graft and acellular dermal matrix. The patient had an uncomplicated postoperative course. Five-year strength, sensory and patient reported outcomes represent overall satisfactory results. Strength testing revealed the injured hand to perform within 90% strength of the uninjured side. Sensory outcomes showed present but diminished sensory perception in each of the injured digits. The patient's upper extremity function, physical health, quality of life, and foot health were overall acceptable, and he returned to using his hand for typing, writing, weight-lifting, and woodworking.

Functional Improvement with Free Vascularized Toe-to-hand Proximal Interphalangeal (PIP) Joint Transfer

Supplemental Digital Content is available in the text.

Background:

Reconstruction of small joints of fingers is still challenging in hand surgery. Implant arthroplasty and arthrodesis have some limitations in the reconstruction of small finger joints. Free vascularized PIP joint transfer from second toe to finger is a promising autogenous reconstructive alternative.

Methods:

In this prospective study, 7 cases of free vascularized PIP joint transfer were analyzed. The measurements for active and passive range of motion (ROM), grip, and pinch strength has been done preoperatively and 1-year postoperatively. The functional change in daily life quality and work-related activities was evaluated with Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire.

Results:

Mean follow-up period was 20.3 months (12–25). Preoperative mean active and passive ROM values were 3.6° (0–14°) and 11.9° (0–29°), respectively. Postoperative 1-year measurements revealed a mean active ROM of 24.1° and a mean passive ROM of 31.6°. Mean grip and pinch strength increased from 52.1 to 58.6 lbs and from 5.1 to 5.9 lbs, respectively. Mean preoperative and postoperative DASH-scores were 41.3 and 30.3.

Conclusion:

The improvement in ROM, increasing grip strength, and declining DASH scores in our study support that free vascularized joint transfer improves patients’ daily life quality and work-related activities via providing a functional joint if performed with appropriate indications, careful planning, and meticulous surgical execution. Free vascularized joint transfer provides an autogenous, painless, mobile, and stable joint. It also has the advantages of composite tissue reconstruction and lacks the disadvantages of arthrodesis and synthetic joint implants.

Microvascular Toe Joint for Proximal Interphalangeal Joint Replacement: Indications, Technique, and Outcomes

Microvascular toe interphalangeal joint transfer can serve as a means of autogenous digit proximal interphalangeal joint (PIPJ) arthroplasty. Among surgical options for treating dysfunctional, absent, or destroyed PIPJs, free toe joint transfer is the most technically challenging and carries the greatest donor site cost to patients. Despite drawbacks, free toe joint transfer is a valuable tool with considerable advantages over conventional arthroplasty in the appropriate clinical setting. Particular advantages include lifelong durability, coronal plane stability, low infection risk, and growth potential in skeletally immature patients. This technique requires a balanced assessment of the risk-to-benefit ratio for each patient.

Customizing Extensor Reconstruction in Vascularized Toe Joint Transfers to Finger Proximal Interphalangeal Joints: A Strategic Approach for Correcting Extensor Lag

BACKGROUND

Vascularized toe proximal interphalangeal joint transfer allows the restoration of damaged joints. However, extensor lag and poor arc of motion have been reported. The authors present their outcomes of treatment according to a novel reconstructive algorithm that addresses extensor lag and allows for consistent results postoperatively.

METHODS

Vascularized toe joint transfers were performed in a consecutive series of 26 digits in 25 patients. The average age was 30.5 years, with 14 right and 12 left hands. Reconstructed digits included eight index, 10 middle, and eight ring fingers. Simultaneous extensor reconstructions were performed and eight were centralization of lateral bands, five were direct extensor digitorum longus-to-extensor digitorum communis repairs, and 13 were central slip reconstructions.

RESULTS

The average length of follow-up was 16.7 months. The average extension lag was 17.9 degrees. The arc of motion was 57.7 degrees (81.7 percent functional use of pretransfer toe proximal interphalangeal joint arc of motion). There was no significant difference in the reconstructed proximal interphalangeal joint arc of motion for the handedness (p = 0.23), recipient digits (p = 0.37), or surgical experience in vascularized toe joint transfer (p = 0.25). The outcomes of different techniques of extensor mechanism reconstruction were similar in terms of extensor lag, arc of motion, and reconstructed finger arc of motion compared with the pretransfer toe proximal interphalangeal joint arc of motion.

CONCLUSION

With this treatment algorithm, consistent outcomes can be produced with minimal extensor lag and maximum use of potential toe proximal interphalangeal joint arc of motion.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

A Novel Technique for Correcting Extensor Lag in Vascularized Toe PIP Joint Transfers

The use of the vascularized second-toe proximal interphalangeal joint (PIPJ) for vascularized joint transfers (VJTs) allows for restoration of powerful pinch/grasp and range of movement of a PIPJ in the hand. However, because of the lack of central slip formation in the majority of toes, the reconstructed PIPJ often results in extension lag. Extension lag associated with poor central slip formation in the lesser toes can be corrected using central slip reconstruction methods such as the Stack method. However, such methods are often cumbersome and involve extensive dissection and soft tissue manipulation. We present a novel, reproducible, simple yet effective technique in recreating the insertion point of the extensor tendon in the reconstructed finger, hence correcting the issue of extensor lag in vascularized toe joint transfers. The crux of this technique empowers the surgeon with the ability to correct inherent extensor lag of toes in VTJs. This will hence nullify "toe PIPJ angles" as a preselection criteria in determining patients suitable for VJT, thus enabling more patients to benefit from VJTs.

Proximalization of the Vascularized Toe Joint in Finger Proximal Interphalangeal Joint Reconstruction: A Technique to Derive Optimal Flexion From a Joint With Expected Limited Motion

When used to reconstruct a finger proximal interphalangeal joint, a free toe interphalangeal joint, without modification, cannot meet the motion demands of the finger to allow palm touchdown. This limitation is the direct result of the toe interphalangeal joint having an intrinsic arc of motion that delivers less flexion than that of a normal functioning finger proximal interphalangeal joint. By modifying the inset of the transferred joint to an extra-anatomical more proximal position, this limitation can be overcome. With a mathematical justification highlighted by a clinical illustration, we demonstrate the feasibility and utility of this "proximalization" technique.

Chondrocyte Viability 3.5 Years Following a Vascularized Medial Femoral Trochlea Osteocartilaginous Free Flap

CASE

A 30-year-old woman underwent arthroscopy for wrist pain 3.5 years following a medial femoral trochlea (MFT) osteocartilaginous free flap for Kienböck disease, which provided the opportunity to examine the transferred cartilage in vivo. Arthroscopy revealed no evidence of chondrolysis, and histologic examination revealed uniformly viable chondrocytes within a matrix consistent with fibrocartilage.

CONCLUSION

To the best of our knowledge, the long-term viability of chondrocytes following an MFT free flap has not been previously documented. This case provides early evidence that free tissue transfer based on the descending genicular artery can provide a durable solution for osteocartilaginous defects.

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.

New option for surgical treatment of the trapeziometacarpal osteoarthritis: a case report

We present the case of a 71-year-old, left-handed woman with left thumb carpometacarpal (CMC) joint arthritis. The patient had no pain and could use the hand actively in daily life with a new option of surgical treatment, a vascularized pedicled third CMC joint transfer to the thumb CMC joint.

Vascularized graft from the metatarsal base for reconstructing major osteochondral distal radius defects

PURPOSE

To present our experience of reconstructing distal radius articular defects with a vascularized osteochondral graft from the metatarsal base and to present the mid-term outcomes.

METHODS

Seven patients (average age, 36 y; range, 26-55 y) who had reconstruction of major defects of the articular surface of the radius are presented. In 5, the lunate facet and sigmoid notch were reconstructed; in 1, an isolated defect on the surface of the lunate facet was reconstructed; and in 1, the scaphoid facet was reconstructed. In 6, the base of the third metatarsal was transferred, and in 1, the base of the second was transferred.

RESULTS

All flaps survived without complications. At the latest follow-up (range, 20 mo to 8 y), the flexion-extension arc improved an average of 50°, and the pain on a visual analog scale decreased from 8 to 1 on average. Disabilities of the Arm, Shoulder, and Hand score improved from 54 to 11 on average. One patient did not improve. No major complaints related to the donor site were mentioned (average American Orthopedic Foot and Ankle Society score of 96/100).

CONCLUSIONS

Our mid-term results are promising; however, the decision-making process and the operation are complex. The operation is not indicated when the carpals are devoid of cartilage or when the defect involves the whole radius surface.

Vascularized medial femoral trochlea osteocartilaginous flap reconstruction of proximal pole scaphoid nonunions

PURPOSE

The descending geniculate artery's branching pattern includes periosteal vessels supplying the cartilage-bearing trochlea of the medial patellofemoral joint. Previous cadaveric studies described anatomic similarities between the greater curvature of the proximal scaphoid and the convex surface of the medial femoral trochlea (MFT). We describe the technique and report our first 16 consecutive cases of vascularized osteocartilaginous arthroplasty for chronic scaphoid proximal pole nonunions using the MFT, with a minimum of 6 months of follow-up.

METHODS

Chart reviews of 16 consecutive cases of osteocartilaginous MFT flap transfers for scaphoid reconstruction were performed at 2 institutions. Follow-up data were recorded at a minimum of 6 months, with an average of 14 months (range, 6-72 mo). Patient age and sex, duration of nonunion, number of previous surgical procedures, surgical technique, achievement of osseous union, preoperative and postoperative scapholunate angles, preoperative and postoperative range of motion, and pain relief were recorded.

RESULTS

Computed tomography imaging confirmed healing in 15 of 16 reconstructed scaphoids. Mean patient age was 30 years (range, 18-47 y). The average number of previous surgical procedures was 1 (range, 0-3). All patients experienced some wrist pain improvement (12/16 complete relief, 4/16 incomplete relief). Wrist range of motion at follow-up averaged 46° extension (range, 28° to 80°) and 44° flexion (range, 10° to 80°), which was similar to preoperative measurements (average 46° extension and 43° flexion). Scapholunate relationship remained unchanged with average scapholunate angles of 52° before surgery and 49° after surgery.

CONCLUSIONS

Osteochondral vascularized MFT flaps provide a reliable means of achieving resolution of difficult proximal pole scaphoid nonunions. These flaps allow resection of the proximal portion of the unhealed scaphoid and reconstruction with an anatomically analogous convex segment of cartilage-bearing bone. This technique provides the advantages of vascularized bone and ease of fixation. Early follow-up demonstrates a high rate of union with acceptable motion and pain relief.

CLINICAL RELEVANCE

Early follow-up suggests that the vascularized MFT osteocartilaginous flap is a valuable tool for treating challenging proximal pole scaphoid nonunions.

Reconstruction of the ulnar head with a vascularized second metatarsal head: case report

A case of a young patient with avascular necrosis of the ulnar head following a severely displaced ulnar head fracture is presented. Treatment included debridement of the entire ulnar head, leaving the ulnar styloid, sigmoid notch, triangular fibrocartilage, and both distal radioulnar ligaments intact. The head of the ulna was reconstructed by transferring a vascularized second metatarsal head. At 4-year follow-up, the patient had a pain-free wrist with 45° active pronation and 65° supination. He resumed working without limitations as a manual laborer. We conclude that ulnar head reconstruction with a vascularized second metatarsal head is worthwhile in the setting of an unreconstructable traumatic defect, particularly when the sigmoid notch and distal radioulnar ligaments are preserved.

Prosthetic hemi-arthroplasty for post-traumatic articular cartilage loss in the proximal interphalangeal joint

This article discusses the indications, contra-indications, and technique for proximal interphalangeal joint prosthetic hemi-arthroplasty in the setting of sub-acute or chronic post-traumatic articular cartilage loss. Two case examples are provided: one for replacement of the head of the proximal phalanx, the other for replacement of the base of the middle phalanx.This procedure serves as a recently available alternative to fusion, silicone total joint replacement, total joint arthroplasty with unlinked surface replacements, volar plate arthroplasty, hemi-condylar osteochondral autograft reconstruction, or free vascularized joint transfer.

[Vascularized rotatory transfer of the trapezoid-trapeziometacarpal bi-articular complex for treatment of severe TMC-joint arthritis]

A new surgical technique to reconstruct the basal joint of the thumb, to treat persistent pain, restore stability and function, due to severe degenerative osteo-arthritis, is here presented. Our research on the anatomo-topographical and bio-mechanical aspect of the Trapezium-Trapezoid-Metacarpal bi-articular complex (TM-TZM) has led us to observe that trapezoid-metacarpal joint (TZM) is a working joint, which has remained inactive for many years, a true joint bank for the TM joint. When it is transposed at the base of the thumb column, it is obliged to move according to the active movements of the intrinsic and the extrinsic muscles. Since January 1998, 34 patients have been operated on, replacing the trapezio-metacarpal (TM) joint with trapezoid-metacarpal (TZM) joint and vice-versa. Rotatory transfer of trapezoid-metacarpal pro-trapezio-metacarpal joint was achieved preserving entirely the intrinsic ligaments and the dorsal branch of the radial artery, which rotates palmarly with the biarticular complex thus ensuring vascular supply. Procedure consists in a wrist dorso-radial approach, metaphyseal osteotomy of first and second metacarpal bases, capsulotomy all around and rotatory transfer of the bi-articular complex, stabilization with K wires of osteotomies and capsulo-ligamentous reconstruction. Follow-up evaluation of the patients ranged between 3 months and 10 years (mean 4 years). Results have been excellent in 24 cases and good in 10. Painless motion, stability due to the first metacarpal ray length reconstruction with a subsequent redistribution of forces along the entire axis, restored thumb opposition, pinch and grip strength of the hand have been obtained. In conclusion, this technique represents now a new surgical opportunity for a surgeon to choose a straightforward and reliable treatment in a wider range of care for degenerative arthritis or severe and destructive trauma of the TMC joint. A greater number of cases and a longer follow-up are necessary for a wider evaluation of the procedure.

[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.

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

Since arthroplasty, prosthetic replacement and non-vascularised articulation autografting do not normally produce very satisfactory results for ankylosis of metacarpophalangeal and interphalangeal joints, the authors performed reconstruction of phalangeal articulations of the hand using vascularised phalangeal articulations of the foot in 11 patients with ankylosis of the metacarpophalangeal and interphalangeal joints of hand due by trauma. Procedures included reconstruction of 9 hand metacarpophalangeal joints with vascularised grafting of pedal metatarsophalangeal joints in six patients, reconstruction of the hand metacarpophalangeal joints with grafting of vascularised proximal interphalangeal joints of foot in two patients and reconstruction of the hand proximal interphalangeal joints with grafting of vascularised proximal interphalangeal joints of foot in three patients. Early functional exercise was encouraged in all cases post-operatively. Follow-up ranged from 3 to 10 years and revealed that 9 cases had normal appearance and length of recipient area, 1 had slightly clumsy dorsal skin in the hand and 1 had slight dorsal angulation of a metacarpal bone. Recovery of joint range of motion was satisfactory. Radiographic, gross and sensation examinations also showed good operative outcomes. The authors believe that vascularised pedal metatarsophalangeal joints, with a rich blood supply, can be grafted to effectively reconstruct the finger joints with good function. A low rate of degeneration results because pedal and hand metatarsophalangeal joints are similar in anatomy and physiological function.

Evolving concepts in the management of the bone gap in the upper limb. Long and small defects

Vascularised bone graft is a well accepted technique when dealing with long defects. Its role in refractory nonunion, in small defects and in the growing patient is rarely discussed. In this paper the authors review the different alternatives to deal with bone defects in the upper extremity. The indications of vascularised corticoperiosteal graft for solving small defects harbouring refractory nonunion, and the use of vascularised bone phalanx and metatarsal for complex - but small - defects in the fingers is presented. The ability of the bone to grow and remodel when a living epiphysis is included, and to maintain the cartilage viability when a composite osteochondral graft is transferred are also discussed.

Vascularized bone blocks from the toe phalanx to solve complex intercalated defects in the fingers

PURPOSE

Vascularized bone transplants resist infection and allow rapid healing but keeping small bony segments vascularized, as needed for a finger defect, is a challenge. The purpose of this article is to present a cohort of patients with traumatic intercalated compound bony defects in the fingers that were reconstructed by a vascularized toe phalanx (or part of a phalanx) in a single stage.

METHODS

Eight patients were treated with an intercalary vascularized bone graft that included a part of the proximal phalanx (3 patients), most of the middle phalanx (4 patients), or a portion of each phalanx (1 patient) of a second toe (totaling 9 bone blocks). There was an associated soft-tissue defect in each patient, an infection in 6 patients, and cartilage loss in 4 patients. The toes were pedicled on the proper digital artery (6 patients) or a segment of the first dorsal metatarsal artery (2 patients). A mean length of 12 mm of vascularized bone was transferred. The associated skin island varied from a minimum of 2 x 1 cm to a maximum of 5 x 3 cm. Bleeding from all of the bone surfaces was evidenced once the clamps were released. The homolateral digital nerve and the contralateral neurovascular pedicle of the toe were kept in place. The toe defect was treated by soft-tissue arthroplasty or arthrodesis. No toe was amputated.

RESULTS

Radiologic bony union was evident at 4 to 6 weeks, except in 1 patient with an acute infection whose distal union failed to unite at 6 weeks because the infection recurred. Finger length loss averaged 3 mm. All patients returned to their preoperative occupation.

CONCLUSIONS

In this group of patients the toe phalanx reliably maintained its vascularization, allowing us to solve compound osteocutaneous defects in the fingers in a single stage. Donor site morbidity was minimal.

Reconstruction of the distal radius facet by a free vascularized osteochondral autograft: anatomic study and report of a patient

PURPOSE

Large chondral defects of the distal radius after fractures present a reconstructive challenge. The purpose of this study was to present the anatomic findings from a cadaver of a vascularized osteochondral autograft taken from the third metatarsal appropriate for reconstructing the distal radius articular facet. A patient is presented in whom 70% of the scaphoid fossa was reconstructed with this technique.

METHODS

The base of the third metatarsal was studied in the feet of 20 cadavers. The size and shape of the cartilage were measured. Additionally vessel distribution was recorded and the diameters of vascular foramina were measured with Juch's method.

RESULTS

The base of the third metatarsal is pear shaped and is wider dorsally than plantarly. It averages 19.2 mm long on its main axis. Its cartilaginous surface is minimally concave or flat and it is slanted slightly proximal-dorsal to distal-plantar and proximal-peroneal to distal-tibial. Nutrient foramina were found in every case in the dorsum and on both sides of the proximal shaft. At least 1 nutrient vessel could be tracked back to the dorsalis pedis in every dissected specimen.

CONCLUSIONS

The anatomic features of the base of the third metatarsal make it a potential vascularized autograft to consider for osteochondral defects of the distal radius.

Results of osteotomy, open reduction, and internal fixation for late-presenting malunited intra-articular fractures of the base of the middle phalanx

PURPOSE

To present our results in the treatment of late-presenting impaction fractures of the base of the middle phalanx treated by osteotomy with full exposure of the articular surface to restore the normal anatomy.

METHODS

Eleven patients with a malunited (impacted) fracture of the base of the middle phalanx were treated by osteotomy more than 5 weeks after the injury. All fractures had varying degrees of impaction, comminution, and dorsal subluxation. The malunited joint surface was visualized by dislocating the joint by hyperextension (shotgun approach). The restoration of the cup-shape contour of the middle phalangeal base was accomplished by osteotomy and mobilization of small osteochondral fragments. Rigid fixation was performed by cerclage wire, screws, or a combination of these. A distal radius bone graft was placed beneath disimpacted fragments in 9 of the 11 procedures.

RESULTS

Ten of 11 patients were followed-up for more than than 1 year. One patient with a volar lateral impaction fracture was lost to follow-up study 4 weeks after the surgery and was excluded from the results. All patients except 1 achieved a functional range of motion of the proximal interphalangeal joint. Moderate limitations of the distal interphalangeal joint motion were common. Grip and thumb-affected finger tip pinch strengths were 95% and 90%, respectively, of the healthy side. The average pain level (as rated on a visual analog scale of 0-10) improved from a preoperative score of 9.1 to a postoperative score of 0.8. One patient was somewhat dissatisfied; all other patients were satisfied or very satisfied. All returned to their previous work at an average of 13 weeks after surgery.

CONCLUSIONS

Favorable results have been achieved in this challenging scenario in the short- and middle-term in 9 of 10 patients. Previous surgery and moderate to severe wearing of the cartilage of the proximal phalanx head negatively affected the results.

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.

Finger joint fusion with the aid of an aluminum template

The author presents a simple technique of the finger joint fusion. The aluminum template is used to make the correct bone cutting and to facilitate the PIP joint fusion in a useful position.