Posttraumatic thumb reconstruction

Mangled Thumb Injury Reconstruction with the Use of Definitive External Fixation and the Masquelet Technique: A Case Report

CASE

A 23-year-old right-hand dominant man presented with a high-velocity gunshot wound injury to the right thumb with severe soft-tissue damage, vascular injury, and large osseous defect of the right thumb metacarpal. The patient was successfully treated with metacarpophalangeal joint arthrodesis and metacarpal reconstruction using definitive external fixation, an intramedullary Kirschner wire, and use of the Masquelet bone grafting technique.

CONCLUSION

The authors' treatment approach for a mangled thumb injury with definitive external fixation and utilization of the Masquelet technique resulted in restoration of a large osseous defect, avoidance of infection, and limited loss of mobility.

The Pedicled Sensate Osteocutaneous Groin Flap for Reconstruction of the Forearm and Hand

BACKGROUND

The groin flap is axial pedicled and versatile. Until now, this flap has been used with many modifications for the reconstruction of forearm and hand defects. However, this flap has not been used in forearm, hand, and thumb reconstruction as a pedicled sensate osteocutaneous flap. In this study, a pedicled sensate osteocutaneous groin flap was used for the reconstruction of composite tissue defects on the forearm, hand, and thumb.

PATIENTS AND METHODS

A pedicled sensate osteocutaneous groin flap was used to reconstruction composite tissue defects on the forearm, hand, and thumb in 7 patients. The mean age of the patients was 42 years. The defects were located on the dorsal surface of the forearm and hand in 2 patients, the dorsal surface of the hand and finger in 2 patients, and the thumb in 3 patients. The dimensions of the flap skin paddle ranged from 7 × 11 cm to 8 × 23 cm, and the dimensions of the bone component ranged from 1 × 1.5 × 3.5 cm to 1 × 1.5 × 5 cm. The mean follow-up duration was 26 months.

RESULTS

All the flaps survived. Flap debulking was performed using 3 flaps. Sensory recovery in the flaps was completed approximately 18 months after the first operation. When the results of static 2-point discrimination test and Semmes-Weinstein monofilament test were evaluated at 18 months postoperatively, it showed that protective sensation was obtained. Except for 1 patient, motion restriction did not develop in the wrist, elbow, or shoulder joints. An acceptable aesthetic result, minimal donor site deformity, and protective sensation were obtained in all patients.

CONCLUSIONS

The pedicled sensate osteocutaneous groin flap can be safely used in the reconstruction of forearm and hand composite tissue defects that do not have available vascular structures for free flaps in the recipient area and in thumb reconstruction where toe transfer and pollicization cannot be performed.

Functional and aesthetic recovery of the second toe defect using a wrap-around pedicled flap from the great toe

We report the results of using a fibula-sided digital artery pedicled flap from the great toe to cover the second toe free flap donor site, which avoids delayed wound healing, and prevents pain and skin ulceration. This study included 15 patients who had second toe wrap-around free flaps to reconstruct thumb and finger defects. All 15 pedicled flaps used to cover the defect healed uneventfully. All patients were able to stand and walk and were satisfied with the postoperative aesthetic outcome at the 6-month follow-up. We conclude that this an effective procedure for preventing donor site defects after second toe wrap-around free flap transfer.Level of evidence: IV.

A Customised paediatric thumb web splint for management of adduction contracture of thumb

The thumb web has a unique anatomy, the integrity of which is vital to both form and function of the hand. Thumb web space adduction contractures are a common consequence of hand burns and are a progressive disabling deformity and prevention or early intervention is advisable. This case describes the use of a customised removable web splint in children with scarring and gradual contracture of the first web space causing pain with movement and significant restriction in the hand function to maintain the thumb web expansion. This inexpensive and effective appliance can be safely applied to an injured hand, maintain web space following surgical release and allows movement at the first carpometacarpal joint and hence obtains a good functional outcome.

Reconstruction of Finger Soft Tissue Defects With a Thinned Free Anterolateral Thigh Flap

BACKGROUND

Reconstructing complex soft tissue defects of the finger requires both functional and aesthetic aspects. There are many free tissue transfers as suitable options for digital resurfacing. The anterolateral thigh (ALT) flap is not the first choice for reconstruction of this area because it has the disadvantage that the subcutaneous tissue is too thick; however, its use as a thinned form has yet to be described much. This study presents the flap thinning technique in the small-sized ALT flap for the finger soft tissue defect.

METHOD

From May 2009 to March 2018, 10 patients with complete circumferential or semicircumcision defects in the fingers underwent reconstructive procedures that included thinned ALT flap transfer. Finger soft tissue damage due to contusion trauma includes loss of skin and exposure of the bone and tendon. The flap is thinned in 2 different ways: peripheral thinning and total microsurgical thinning, which is selected based on the perforator vessel structure of the flap.

RESULT

The ALT flap sizes, averaging 4-9 cm wide and 6-12 cm long, were thinned to 4-7 mm. One perforator was included in the flaps with a pedicle length average of 6.1 cm. The flaps survived entirely in all patients except one with a 30% area in the distal part of the thinned ALT flap that became necrotic because of venous occlusion. Donor sites were closed primarily for all patients. No patients required secondary flap defatting.

CONCLUSIONS

The small thinned ALT perforator flap can be an excellent option for full circumferential or semicircumferential soft tissue defects of the finger. Follow-up showed this as an excellent alternative for finger reconstruction in terms of aesthetic appearance and functional outcome.

Three-Dimensional Computer-Aided Design Modeling and Printing for Accurate Toe-to-Hand Transplantation

PURPOSE

To introduce toe-to-hand transplantation performed with the assistance of both bone and soft tissue modeling using 3-dimensional printing technology.

METHODS

From May 2015 to October 2018, 31 patients (group A, 24 thumbs and 7 fingers) were included. Computed tomography scans were acquired using a spiral computed tomography scanner, and the data were processed with software. Bone, skin, and nail models were created for tailoring the flap taken from the great toe. The impact of foot pathology in terms of pain, disability, and activity restriction was assessed using the Foot Function Index. For comparison, we included 35 patients (group B) who underwent toe-to-hand transplantation without the assistance of 3-dimensional computer-aided modeling.

RESULTS

The mean duration of follow-up of groups A and B was 26 months (range, 24-31 months) and 27 months (range, 24-33 months), respectively. The mean Foot Function Index of groups A and B was 5 (range: 0-15) and 17 (range, 0-39), respectively.

CONCLUSIONS

Three-dimensional computer-aided modeling and printing provide geometric accuracy in toe-to-hand transplantation. It also may reduce the donor foot morbidity by accurate flap designing and harvesting.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

A comparative study of thumb reconstruction through the transplant of the first toe compound free flap between emergency surgery and elective surgery

This study compared emergency surgery with elective surgery for thumb reconstruction to explore the advantages, safety, and clinical value of emergency reconstruction. By comparing the advantages and disadvantages of thumb reconstruction in emergency surgery and elective surgery, it provides data support for optimizing the treatment process and methods. In this study, 22 patients who underwent thumb reconstruction in Rizhao people's Hospital from January 2018 to December 2020 were randomly divided into emergency operation group and elective operation group. The differences in operation period, hospitalization time, postoperative complications, hand function score, and satisfaction score between the 2 groups were analyzed. The operation period and hospitalization time of patients in the emergency surgery group were significantly lower than those in the elective surgery group, with statistical significance (P < .05). There was no significant difference in postoperative complications between the 2 groups (P > .05). After 3 months of rehabilitation training, the 2-point discrimination, functional score, and satisfaction score of the reconstructed thumb in the emergency surgery group were higher than those in the elective surgery group, and the difference was statistically significant (P < .05). Emergency reconstruction of the thumb can reduce operation time and hospitalization time, reduce operation costs, and obtain a more ideal appearance and function.

Osteoplastic Thumb Reconstruction in the Immediate Setting: A Case Series

Background

Traumatic thumb amputation can have devastating effects on residual hand function. When replantation is not possible, thumb reconstruction is often performed in a delayed manner and may require multiple stages. Furthermore, reconstruction techniques often require microsurgical skills and equipment, which are not readily available at all institutions. This case series illustrates our technique for immediate osteoplastic thumb reconstruction following traumatic amputation.

Methods

This is a case series involving all patients who sustained unreplantable thumb amputations and underwent immediate osteoplastic thumb reconstruction with bone autograft and pedicled groin flap by the senior author from September 2016 through August 2018.

Results

Five patients underwent immediate osteoplastic thumb reconstruction during the study period. Total operative time for the initial osteoplastic reconstruction averaged 158 minutes (range 96-290 minutes). In addition to flap division surgery, patients underwent an average of 1.2 revision procedures (range 0-2), primarily for debulking and hardware removal. Patients achieved an average gain in length of 3.3 cm compared with the maximum anticipated length with revision amputation at the time of injury, and had stable clinical outcomes for a minimum of 12 months.

Conclusions

Osteoplastic thumb reconstruction is a useful technique for thumb reconstruction for select patients following traumatic thumb amputation. Advantages of this approach include shorter overall operative times and hospital length of stay, minimal donor site morbidity, and a straightforward, reproducible technique.

Utility of "reposition-flap" in the reconstruction of the avulsed thumb

Injuries that result in thumb amputation cause a loss of 50% of hand function. Microsurgical replantation remains the gold standard of thumb reconstruction techniques. The non-microsurgical technical variants of thumb reconstruction described so far aim to create a neo-thumb of adequate length, stable, opposable, sensitive, and last but not least esthetically pleasing appearance. Avulsion of the distal phalanx and the absence of the nail will determine a functional deficit but also an unesthetic appearance. When replantation is not possible or the patient refuses to "sacrifice" another anatomical region for thumb reconstruction, the "reposition-flap" technique can be used. Although often controversial, this surgical technique deserves proper attention and should be used in some cases. We studied a group of 32 patients with distal thumb amputations. In patients with amputations in zone II according to Tamai, with interphalangeal joint preservation, the thumb was reconstructed using "reposition-flap" with an O'Brien flap in 15 cases. In the remaining 17 cases where the amputation was at the level of the interphalangeal joint, we used the same technique, but the thumb neopulp was reconstructed with the Littler heterodigital neurovascular flap harvested from the ulnar border of the middle finger in 11 cases or radial border of the ring finger in 6 cases. The results were evaluated from a functional (Kapandji score), sensitive (2-point discrimination, Semmes-Weinstein test) but also esthetically (patient satisfaction) point of view. Donor site morbidity, cold intolerance, the presence of nail dystrophy, and bone resorbtion were also assessed. The disabilities of the arm, shoulder and hand score was evaluated for each patient. Although various surgical and microsurgical techniques for thumb reconstruction are described, when choosing the technique to use we must first consider patient's wishes. A well-informed patient will be able to make, with the surgeon, the best decision for him concerning the reconstruction option.

Application of a modified dorsoulnar artery pedicle flap in the repair of thumb tip defects: A case report

Between February 2012 and March 2014 10 patients were admitted to the Affiliated Hospital of Nantong University for surgery due to a thumb tip defect. Nine of these patients were male and one was female and there were 7 cases of left thumb defects and 3 cases of right thumb defects. The surgical procedures followed were first, modification of the flap tail to an equilateral triangle, which facilitated pedicle suturing of soft tissue defects, caused mild tension and effectively reduced venous disorders, and second complete opening of the flap pedicle to the soft tissue defects at the tunnel. All patients were followed up at 6 and 12 months after surgery. Grip and pinch strength were measured 6 and 12 months after surgery. Static two-point discrimination testing of the modified flap showed minor differences from the uninjured hand. Post-surgery grip and pinch strength were restored to approximately 85% of the level of that in the uninjured hand. The modified dorsoulnar artery pedicle flap provided excellent thumb tip defect coverage and is an effective and safe technique for the restoration of grip and pinch strength to the hand after the repair of a thumb tip defect.

Contralateral Heterotopic Thumb-to-Thumb Replantation With Free Ulnar Forearm Fasciocutaneous Flap and Targeted Muscle Reinnervation

Mangling hand injuries can be difficult to manage owing to the severity and heterogeneity of the injuries. Outcomes after reconstruction of unique injuries are less well-known but provide valuable insight. We present an unusual spare parts reconstruction of a bilateral upper-extremity mangling injury treated with a heterotopic thumb-to-thumb replantation, an acute forearm fasciocutaneous free flap, and targeted muscle reinnervation. This report highlights the utility of microsurgical reconstruction with available autogenous tissue in the acute setting.

Thumb reconstruction with combination of the wrap-around flap prefabricated by medialis pedis perforator flap with nail bed and phalanx banked from the amputated thumb: A case report

Thumb reconstruction has been a very challenging issue for hand surgeons. In this report, we present a case of thumb reconstruction with combination of the wrap-around flap prefabricated by the medialis pedis perforator flap with phalanx and nail bed banked from the amputated thumb. A 22-year-old man suffered from the left thumb amputation as well as large soft tissue defect of hand and comminuted fracture in wrist due to a crush accident. The distal phalanx and nail bed of left thumb were exposed and no suitable vessels for microsurgical anastomosis could be found, resulting in the great difficulty of replantation. After debridement, nail bed of the amputated thumb was dissected and banked on the medial side of foot, while the distal phalanx was buried in the abdominal subcutaneous tissue. The fracture was fixed with an external fixation and the soft tissue defect was covered with a free anterolateral flap. Wound and bone healing was achieved 6 months after the initial treatment. Thumb was reconstructed with combination of the banked phalanx and a wrap-around flap prefabricated by the medialis pedis perforator flap and the banked nail bed. The postoperative course was uneventful with complications from both reconstruction and donor sites. The nail of the reconstructed thumb grew normally. Thumb oppositional function was rebuilt. The patient was satisfied with the aesthetic and functional outcome at 5-year postoperative follow-up. We propose that tissue banked from the nonreplantable amputated thumb could be used for secondary reconstruction with the technique of flap prefabrication.

The Masquelet Technique for Thumb Metacarpal Reconstruction Following Trauma: A Case Report

CASE

We describe an unusual case of an isolated close-range shotgun injury to the thumb with substantial osseous loss and intact vascularity, followed by treatment with the Masquelet technique and iliac crest tricortical bone autograft reconstruction.

CONCLUSION

Gunshot injuries to the thumb with concomitant soft-tissue and osseous loss are devastating. Reconstruction depends on the level of the injury, the severity of the soft-tissue and osseous damage, and the viability of the digit, as well as patient factors, including occupation, physical demands, and expectations.

Microsurgical thumb repair and reconstruction

In this article, we review microsurgical reconstructive techniques available to treat thumb amputation at different levels based on our experience. We reference techniques used by other surgeons and identify the most suitable technique for different clinical situations. Indications and techniques for microsurgical partial or composite transfer of the great or second toe for thumb reconstruction are summarized. Different microsurgical transfer techniques suggest a great freedom of surgical choices. However, the choices are considerably restricted if all functional and cosmetic requirements are to be met. We recommend individualized surgical design and reconstruction because each case of thumb amputation is unique.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Therapeutic, Level IV.

Challenges Posed by Delayed Presentation of Mutilating Hand Injuries

Management of mutilating hand injury is a challenge for any hand surgeon. Delay in presentation makes management even more challenging, usually because of inadequate initial assessment, inadequate debridement leading to infection, and secondary loss of tissues from exposure and desiccation. The aim is to obtain a functional hand by radical debridement, adequate assessment of the injury, appropriately timed reconstruction, and physiotherapy and rehabilitation. The hand surgeon must pay attention to the appearance of the hand by elimination of deformities, unsightly scars and bulky flaps to help to restore confidence in the patient to face the demands of daily living.

Osteoplastic Reconstruction for Post Traumatic Thumb Amputations Around Metacarpophalangeal Joint

INTRODUCTION

Loss of a thumb due to trauma warrants replantation which is the best method of reconstruction. When replantation is not possible, thumb reconstruction is the procedure of choice. The level of thumb amputation guides the type of reconstruction. There are five goals for reconstructing a thumb: restoration of (1) functional length (2) stability (3) mobility (especially opposition) (4) sensibility and (5) aesthetic appearance.

AIM

This study was conducted to evaluate the functional outcome of two main techniques of osteoplastic thumb reconstruction (1) Osteocutaneous distally based radial forearm flap (2) Groin flap with iliac crest bone graft.

MATERIALS AND METHODS

Total 13 patients underwent osteoplastic reconstruction in the duration from August 2012 to December 2014. Thumb reconstruction was done using distally based radial forearm osteocutaneous flap in 7 patients and two staged reconstruction by groin flap with iliac crest bone graft in 6 patients. Postoperatively results were assessed in terms of range of motion, hand grip, functional recovery, donor site morbidity and patient satisfaction.

RESULTS

All reconstructive thumbs were functionally acceptable. Cosmetically, donor site morbidity was an issue for 2 patients with radial forearm flap and 1 patient with groin flap. Suture line dehiscence and plate exposure required intervention in local anaesthesia in one patient with radial forearm flap. After reconstruction absence of pain, temperature and touch sensation were observed.

CONCLUSION

We suggest that osteoplastic reconstruction is a reliable procedure in terms of stability, length, strength and opposability if basal joint is intact. Most of the patients in this study were manual labourers who went back to previous occupation and were able to use their thumb for daily activities for earning livelihood.

Functional reconstruction of subtotal thumb metacarpal defect with a vascularized medial femoral condyle flap: case report

Devastating hand injuries require customized reconstructive strategies to maximize functional outcomes. We report a case of thumb metacarpal reconstruction using a vascularized medial femoral condyle osteocutaneous flap in the setting of nearly complete metacarpal loss. In addition to achieving the traditional goals of reconstructing thumb length and providing stability, the medial femoral condyle flap allowed motion at the carpometacarpal joint. The patient's hand function was further optimized by a component transfer of a proximally injured but distally preserved index finger to the amputated middle finger position. The patient regained satisfactory grip and thumb function with minimal donor site morbidity. This case highlights the role of both creative and established approaches to reconstruct composite tissues following devastating hand injury.

Use of twin dorsal middle phalangeal finger flaps for thumb or index finger reconstruction

Amputation or degloving injuries of the thumb or index finger are highly disabling. We describe the use of twin dorsal middle finger flaps harvested from the dorsal aspects of the middle and ring fingers, and based on one palmar proper digital artery, its venae comitantes, and the dorsal branches of the palmar digital nerves of the middle and ring fingers, respectively. These flaps offer advantages when large soft tissue defects of the thumb or index finger are present. In this study, twin dorsal middle finger flaps were used in nine patients (six thumbs, three index fingers). All flaps completely survived. At the mean follow-up of 20 months, the appearance of the reconstructed thumbs or index fingers was acceptable, the length was maintained, and the mean static 2-point discrimination values were 10 mm in the palmar flap and 13 mm in the dorsal flap of the reconstructed digit. All patients were satisfied with the appearance and mobility of the donor fingers. All but one donor finger showed normal finger pulp sensibility, with a static 2-point discrimination between 3 and 6 mm.

Alternative method for thumb reconstruction. Combination of 2 techniques: metacarpal lengthening and mini wraparound transfer

Amputation at the proximal phalanx or at the metacarpophalangeal joint can be treated by pollicization of a finger, osteoplastic reconstruction, free microvascular transfer of a toe, or distraction lengthening. The best technique to use to treat these cases depends on the place of amputation and the patient's age, sex, occupation and functional demands. In the past 6 years, we treated 4 patients by lengthening the thumb metacarpal ray and adding a mini wraparound flap from the great toe. All the subjects were female with an average age of 22 years. All 4 patients had sustained traumatic amputations: 2 at the metacarpophalangeal joint and 2 at the base of the proximal phalanx. Distraction was completed approximately 65 days after osteotomy, obtaining an average lengthening of 23 mm. To achieve bone consolidation, the lengthener was left in place for 127 days on average. Microsurgical thumb reconstruction was performed around 3 months after consolidation of the osteotomy. There were no failures or cases of postoperative vascular compromise. The average pinch power was 66% of the opposite hand. The static 2-point discrimination of the reconstructed thumb was 8 mm (range, 7-10 mm). All patients reported being satisfied with the treatment, although 1 patient was partially dissatisfied due to the prolonged length of the treatment. Donor site morbidity was minimal. This procedure is mainly chosen by selected patients who refuse standard microsurgical thumb reconstruction because it requires a longer treatment period.

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.

Functional outcomes of children with index pollicizations for thumb deficiency

PURPOSE

To gain a comprehensive perspective on outcomes by performing an array of tests on patients who had undergone index pollicization for isolated thumb aplasia or severe hypoplasia in the absence of clinical radial dysplasia; this led us to create a graphical snapshot for future comparison. Another purpose was to compare the function of the contralateral hand and to compare parent and patient perspectives.

METHODS

We evaluated 22 hands (18 patients) by grip as well as lateral and tripod pinch strength tests; the pegboard Functional Dexterity Test (FDT); the Jebsen Hand Function Test (JHFT); and a parent/patient questionnaire. We compared operated hands with both contralateral nonoperated hands and nondominant hands in published normal data. We also compared contralateral nonoperated hands with dominant hands in published normal data, and FDT results and JHFT outcomes in children greater than 6 years old with published normal data. We evaluated questionnaire results.

RESULTS

Mean grip as well as lateral and tripod pinch strength in operated hands were 3.4, 1.2, and 1.2 kg, and in normal nondominant hands were 11.7, 4.4, and 3.9 kg, respectively. Patients' contralateral nonoperated hands were weaker than normal dominant hands. Mean timed FDT results in operated hands was 127 seconds, compared with 44 seconds in published normal data. In 2 of 5 JHFT subtests administered, no difference existed between operated hands and published normal data. A graphical snapshot took various outcome measures into consideration and showed a global assessment. Mean parent and patient questionnaire scores were 10 and 22, respectively (best = 12; worst = 60).

CONCLUSIONS

Comprehensive subjective and objective outcome testing suggested that an optimistic view of function after index pollicization is warranted. A graphical snapshot followed function over time. The contralateral hand fared worse than published normal data. Parent and patient perspectives were favorable.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Opponensplasty provides predictable opposable tripod pinch in toe transfer for proximal thumb ray defect reconstruction

BACKGROUND

Thumb amputations proximal to the metacarpophalangeal joint inevitably result in destruction of the thenar musculature and secondary loss of opposition. Opposable tripod pinch is one of the essential goals in toe-to-thumb reconstruction. Pronation osteosynthesis is the traditional method of restoring opposition, but a simultaneous opponensplasty may turn this static process into a dynamic one.

METHODS

From 1992 to 2010, 19 toe-to-thumb transfers at and proximal to the metacarpophalangeal level with concomitant thenar muscle damage were examined. All underwent either pedicled groin flap (n = 16) or free flap (n = 3) surgery for amputation stump resurfacing. Nine transferred toes had a static opposition procedure with osteosynthesis by rotation of 30 to 60 degrees (group I). Ten transferred toes underwent an additional simultaneous opponensplasty to provide dynamic opposition (group II).

RESULTS

Seventy-eight percent (seven of nine) of group I and 100 percent of group II achieved opposable basic hand function and lateral pinch. In contrast, only 33 percent (three of nine) in group I regained tripod pinch grip compared with 90 percent (nine of 10) in group II, which was statistically significant (p = 0.02).

CONCLUSIONS

Primary opponensplasty in toe transfers provides active restoration of opposition and significantly better restoration of tripod pinch, in comparison with static opposition with osteosynthesis. It is therefore recommended that primary opponensplasty be performed at the time of toe transfer in such injuries.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Thumb reconstruction

Thumb reconstruction aims to restore the cardinal thumb traits and actions including mobility, stability, sensibility, length, and appearance. The level of thumb loss is divided into thirds: distal (tip to interphalangeal [IP] joint), middle (IP joint to metacarpal neck), and proximal (metacarpal neck to carpometacarpal joint). Distal third reconstruction usually requires only soft tissue restoration. Many options exist for middle third reconstruction, including increasing thumb ray length (metacarpal lengthening, osteoplastic reconstruction, toe transfer) and increasing relative length (phalangization). Proximal third reconstruction is best accomplished with toe transfer, pollicization, or on-top plasty (pollicization of a damaged index finger).

Lengthening of a thumb distal phalanx replanted to its metacarpus because of loss of the proximal phalanx: case report

We report a successful thumb replantation by resecting the remnants of the crushed proximal phalanx and uniting the distal phalanx with the thumb metacarpal. The procedure resulted in extreme shortening, which we managed by distraction lengthening and deepening of the first webspace.

Free medial plantar artery perforator flaps for the resurfacing of thumb defects

BACKGROUND

Destruction of the thumb secondary to trauma presents a much more significant influence on daily living than do injuries to the other digits. Various surgical techniques contribute to repair distal defects of the fingers, especially thumb reconstruction.

METHODS

Seven patients received free medial plantar artery perforator (MPAP) flaps to resurface the palmar defects of their thumbs. The flaps can be harvested with or without the main trunk of the medial plantar artery. The perforator of the MPAP flap was anastomosed to a proper digital artery, and the superficial vein of the flap was anastomosed to the dermal vein of the injured finger. These thumbs had no severe length discrepancy or metacarpophalangeal joint injuries. All patients underwent examinations including static 2-point discrimination, moving 2-point discrimination, and Semmes-Weinstein Test Score 6 months after reconstructive surgery. All tests were carried out by the same occupational therapist 6 months after reconstructive surgery.

RESULTS

Five male and 2 female patients were selected for free MPAP flap reconstruction from May 2006 to September 2007. The mobility of the fingers was not restricted after surgery. Six flaps survived completely, and 1 flap partially failed because of venous congestion. Sensory restoration was ideal for all 7 MPAP flaps.

CONCLUSION

The MPAP flap is a suitable choice for reconstructing palmar defects of the fingers, with less donor site morbidity. The cushiony character of the MPAP flap is anatomically similar to the pulp tissue of fingers, and sensory restoration is ideal compared with that of other reconstructive methods. Technical difficulty is focused on anastomosis of perforators (diameter ≤0.8 mm).

Functional and aesthetic results of immediate reconstruction of traumatic thumb defects by toe-to-thumb transplantation

Traumatic thumb defects significantly affect the function and appearance of the hand; thus, thumb reconstruction is very important in clinical practice. In our report, three reconstruction strategies of toe-to-thumb transplantation, based on the amputation level of the thumb, were used for immediate thumb reconstruction in 27 patients with traumatic thumb defects. All procedures were performed successfully. Patients were satisfied with the function and appearance of the reconstructed thumb. These results indicate that if the reconstruction method is properly selected based on the amputation level of the thumb, toe-to-thumb transplantation is feasible for the immediate reconstruction of the thumb.

One-stage osteoplastic reconstruction of the thumb

One-stage osteoplastic reconstruction of the thumb is based on a reverse-flow forearm osteocutaneous flap. It is indicated in traumatic loss of the thumb at or around metacarpophalangeal joint level in situations where replacement with a toe is not feasible or patient desires against such a transfer. It is relatively an easier method of thumb reconstruction and does not require microsurgical expertise. Donor-site morbidity is small. Complications include delayed wound healing at donor site, radius fracture, and venous congestion. This technique is a useful reconstruction option for traumatic loss at the middle-third level of the thumb.

One-stage thumb lengthening with use of an osteocutaneous 2nd metacarpal flap

Traumatic thumb amputation represents an extremely disabling entity, thus rendering its reconstruction a procedure of paramount importance. A case of a patient, who sustained a traumatic amputation of his left index finger at the metacarpophalangeal joint and of his left thumb in the middle of the proximal phalanx 4 months ago and was initially treated elsewhere, is described. For the thumb reconstruction, an osteocutaneous flap of the radial side of the 2nd metacarpal, which consisted of a 3, 5-cm bony segment with the overlying skin and its blood and nerve supply was used. The flap was transferred and fixed with a plate and screws to the palmar-medial side of the stump of the thumb, while the 1st web space was deepened by removing the rest of the second metacarpal, while a partial skin graft was used to cover a remaining gap. Thumb functionality was restored immediately postoperatively, and the overall result was satisfactory.

Application of a fasciocutaneous free flap for treatment of a severe soft tissue injury of the foot and ankle: a case report

The authors report an unusual case wherein a fasciocutaneous free flap from an amputated upper limb was used to repair a severe soft tissue injury of the ipsilateral forefoot and ankle. After amputating the nonviable portions of the forefoot, a residual limb flap from the patient's forearm, pedicled with the brachial artery, was used to cover the lower extremity defect. Three years after the injury, the patient was able to maintain balance and ambulate without assistance on the reconstructed lower extremity.

LEVEL OF CLINICAL EVIDENCE

4.

Immediate reconstruction of a nonreplantable thumb amputation by great toe transfer

BACKGROUND

When replantation of an avulsed/amputated thumb is not feasible, toe-to-hand transfer may be considered as a reconstructive option in appropriately chosen patients. Although selection criteria are purposefully restrictive, immediate one-stage transfer, as opposed to a delayed procedure, provides many advantages. Primary reconstruction reduces hospitalization and operative and recovery time. It also may expedite return of function and allow patients to return to work sooner. The ability of the patient to undergo extensive microvascular reconstruction at the time of injury, the psychological preparation required, and the need to understand potential risks are important factors to consider.

METHODS

In the past 5 years, six patients suffering thumb amputation underwent immediate great toe-to-hand transfer. The overall results of these thumb reconstructions were evaluated retrospectively with regard to function, outcome, length of stay, complications (e.g., infection, contracture, reexploration), and time to return to work/normal activity. The authors calculated objective and subjective scores with which to quantify patient satisfaction and clinical success.

RESULTS

All of the authors' patients were laborers who suffered work-related avulsion-amputations. No complications were reported during initial hospitalization, lasting an average of 12 days. Donor-site morbidity was minimal.

CONCLUSIONS

The data suggest that thumb reconstruction using great toe transfer can be safely and reliably performed during the initial presentation in selected patients. The economic and therapeutic advantages should be weighed against the risks associated with this approach when evaluating thumb avulsion-amputations.

Salvage of a thumb replant using a bilobed dorsal metacarpal artery island flap: case report and literature review

Amputations and degloving injuries of the hand are highly disabling, especially when they affect the thumb. Dorsal metacarpal artery (DMCA)-based flaps have been well-documented in the literature for use in extensive degloving injuries of both dorsal and palmar aspects of the thumb surface. Modifications on these flaps, such as the bilobed island flap, offer additional advantages when larger surface areas or more distal defects of the thumb are present. We present a review of the literature on the DMCA flap and describe its use to salvage a partial survival of a thumb amputation through the metacarpophalangeal joint.

Thumb reconstruction by grafting skeletonized amputated phalanges and soft tissue cover - A new technique: A case series

This study reports five cases of crush-avulsion injury to the thumb at different levels presented at our plastic and hand surgery unit between 2005 and 2007. All of the patients were male labors with machine injuries to the thumb with non-replantable amputations. Distal phalanx or proximal phalanx, or both, were used as a free cortical bone graft. The amputated part was skeletonized keeping the periosteum attached to the cortical bone of the phalanx fixing it to the stump and covering it by either local flap like dorsal metacarpal flap or regional flaps like the distally based pedicled radial forearm flap and neurovascular island sensate flap or groin flap. The results were functionally and cosmetically good and follow up X rays showed no osteoporotic resorption after one year.

Traumatized index finger pollicization for thumb reconstruction

PURPOSE

When the index finger is injured or severed in conjunction with a traumatic amputation of the thumb, transfer of the injured index finger can restore the important function of the thumb. The purpose of this study is to evaluate the results of the transfer of an injured index finger for traumatic loss of the thumb.

METHODS

Seven patients treated by pedicled transfer of a traumatized index finger after amputation to the ipsilateral thumb were reviewed retrospectively. Postoperative evaluations included thumb range of motion, opposition and pinch function, grasp and pinch strength, sensation, a pick-up test, and a patient-rated appearance of the thumb and hand. Vascular patency of the traumatized index finger and thumb was evaluated in each patient prior to thumb reconstruction.

RESULTS

After an average of 4 years of follow-up for surviving patients, all had excellent postoperative function and satisfactory results. The period between injury and thumb reconstruction ranged from 5 months to 4 years. All patients were men with a mean age of 43 years. Amputation levels included the metacarpophalangeal joint in 2 patients, the first metacarpal in 2 patients, and the proximal phalanx in 3 patients. All transferred traumatic index fingers survived without complications.

CONCLUSIONS

Transfer of the injured index finger to the amputated thumb serves as an excellent adjunct for treatment of traumatic thumb amputations/crush injuries. Consistent results can be obtained while maintaining opposition and protective sensation after this procedure. However, technical demands are great, and initial injuries to the thumb and index finger ultimately determine the final outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.