Functional reconstruction of the metacarpal hand with multiple toe transplantations

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.

Functional outcomes of post-traumatic metacarpal hand reconstruction with free toe-to-hand transfer

Introduction:

We present the functional outcomes of microvascular toe transfer to reconstruct the post-traumatic metacarpal hand deformity. Twelve toe transfers were successfully carried out in 11 patients.

Materials and Methods:

In each patient, the level of injury was classified according to the Wei classification system. Functional outcome was measured in seven patients using the Tamai score. Additional objective tests of function were carried out in three patients, including the Jebsen test, grip strength, pinch strength, web opening, static and moving two-point discrimination and Semmes–Weinstein monofilament testing.

Observation and Results:

The average Tamai score was 69 (range 60–83.5). Six patients achieved ‘good’ outcomes and one patient, with a double toe transfer, an ‘excellent’ outcome. The average follow-up time was 43 months (range 10–148 months).

Conclusion:

This study shows how even a single toe transfer can restore useful function to a hand that has otherwise lost all prehensile ability.

Toe-to-thumb reconstruction

Multiple digital losses will result in crippled hand function and toe transfers are proven to provide replacement of prehensile function. Given that basic hand function requires three factors, viz. an ulnar component, a radial component and opposition, various toe transfers can accomplish thumb ray and ulnar digital defect restoration. Opponensplasty and interpositional suspension arthroplasty can provide circumduction to the thumb component required to perform prehensile functions.

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.

Simultaneous Double Second Toe Transfer for Reconstruction of Adjacent Fingers

BACKGROUND

The authors reviewed their results with simultaneous double second toe transfer for reconstruction of adjacent fingers.

METHODS

From January of 1984 to January of 2003, simultaneous double second toe transfer was performed for reconstruction of adjacent fingers in 140 patients (48 before wound closure, 92 after). Functional thumbs were present in all of them. There were 104 male and 36 female patients, with an average age of 29.1 years (range, 2 to 57 years). Index and middle fingers were reconstructed in 90 patients, middle and ring fingers in 49 patients, and ring and little fingers in one patient. The average operation time was 11 hours 25 minutes, which was much shorter than double the average time of a single second toe transfer (8 hours 31 minutes; double time, 17 hours 2 minutes). Twenty-six toes were reexplored for vascular insufficiency and three of them were lost. Secondary surgery was performed in 98 patients to improve function and cosmesis.

RESULTS

Patients were followed up at an average period of 47.5 months (range, 2 to 210 months). Forty-two patients had complete functional evaluation at a minimum 2-year follow-up. The mean active range of motion of the reconstructed finger joints in these patients was 69.4 degrees for metacarpophalangeal joints, 31.1 degrees for proximal interphalangeal joints, and 8.2 degrees for distal interphalangeal joints. Two-point discrimination was between 3 and 13 mm (average, 7.5 mm). All donor sites were closed primarily and no obvious donor-site morbidity was noted, except for one hallux valgus deformity that was corrected by surgery.

CONCLUSIONS

The functional and aesthetic results of double second toe transfers for adjacent two-finger reconstruction are superior to those of a single second toe-to-single finger reconstruction in multiple-finger amputations. Double second toe transfer performed simultaneously reduces the cost and total time of the operation, enables faster rehabilitation, and hastens patient adaptation.