Immediate partial great toe transfer for the reconstruction of composite defects of the distal thumb

Free neurovascular toe-(joint)-transfers compared to alternative reconstructive procedures for amputation injuries of two and tripartite fingers with substance loss

BACKGROUND

Complex injuries of the hand frequently result in loss of essential functional features. Common reconstructive procedures for soft tissue defects of the thumb or phalanges are locoregional flaps like Moberg-, Foucher-, Cross-Finger- or Littler flaps. Microneurovascular toe (joint-) transfers complete the arsenal of operative reconstructive procedures and allow for most detailed reconstructions. Our experiences with free toe transplants are reported and diversely discussed regarding contending procedures.

METHODS

From 2010 until 2019 14 patients who received emergency or elective partial or complete toe transfers were compared with a control group (n = 12) treated with contending reconstructive procedures. Aim of the reconstructions was to cover the defect with well-vascularized, sensate tissue, while preserving length and range of motion in a reliable manner.

RESULTS

The Kapandji score showed a significant difference (p- value = 0.04) with a score of 9.8 in comparison to control group (Kapandji index = 8.0).

CONCLUSION

In our heterogenic patient collective free toe transplants have proven to achieve comparable functional results for reconstruction of two and tripartite phalanxes as opposed to common local reconstructive procedures.

Metacarpal Lengthening Using a Mini-Ring Ilizarov Device for Thumb Reconstruction

PURPOSE

To explore the results of using the mini-ring Ilizarov external fixator for thumb metacarpal lengthening and its compatibility with a simultaneous groin flap.

METHODS

From May 2016 to June 2019, 17 adult patients with thumb loss were treated with metacarpal lengthening using a mini-ring Ilizarov device. The device was composed of 2 rings, threaded rods, nuts, and K-wires (diameter, 1.5 mm). Of these patients, 6 also underwent simultaneous groin flap transfer. Lengthening was started 3 days after surgery at a rate of 0.66 mm/d. The pedicle of the groin flap was divided 1 month after the surgery. The healing index (days per cm), which denotes the number of days the external fixator is attached to the bone per centimeter of length gained, was used to evaluate the lengthening efficiency.

RESULTS

The patients were observed for 21.9 ± 9.0 months. The lengthening continued for 29.1 ± 4.5 days, resulting in an additional length of 1.9 ± 0.3 cm.

CONCLUSIONS

The mini-ring Ilizarov external fixator is a simple device for primary metacarpal lengthening. This device can be used with a groin flap for single-stage lengthening of injured thumbs with bone exposure.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

A mini hallux neurovascular osteo-onychocutaneous free flap for refined reconstruction of distal defects in thumbs and fingers

Distal injury in thumbs and fingers is common in emergency. Although multiple surgical techniques have been introduced for repair purpose, it is still challenging for restoring both good function and cosmetic appearance. The present study reports our experiences on how to reconstruct amputated fingertips in thumbs and fingers using a mini hallux neurovascular osteo-onychocutaneous free flap with favorable outcomes in 15 patients (average age, 27.27 ± 5.43 years old). Follow-up period was 19.47 ± 10.18 months (range, 6-48 months). Digital function was improved indicated by the static two-point discrimination (2-PD) and key-pinch, which were 8.40 ± 1.64 mm (range, 6-12 mm) and 85.37 ± 3.03% (range, 80.2-90.6%) of that of the intact contralateral thumbs and fingers, respectively, after surgery. As to aesthetic outcomes, all reconstructed digits were self-graded as good by patients. 73.3% of the donor halluces were self-graded as good and four halluces (26.7%) were graded as fair. In conclusion, the mini hallux neurovascular osteo-onychocutaneous flap may be used for refined reconstruction of type I amputated injury in thumbs and fingers achieving both satisfactory functional and aesthetic outcomes.

[Application of double osteotomy and lengthening of proximal phalanx and metacarpal with Ilizarov technique for thumb defect]

Objective

To investigate the effectiveness of double osteotomy and lengthening of proximal phalanx and metacarpal with Ilizarov technique in treatment of thumb defect.

Methods

Between February 2017 and June 2019, 6 patients with traumatic thumb defects were treated with double osteotomy and lengthening of proximal phalanx and metacarpal by Ilizarov technique. There were 5 males and 1 female. The age ranged from 28 to 57 years, with an average of 41.5 years. There were 3 cases on the left side and 3 cases on the right side. All patients were admitted to the hospital in emergency department after injury, and the stump of the thumb was trimmed and sutured. The osteotomy plane was the distal part of the proximal phalanx in 4 cases and the interphalangeal joint in 2 cases. The interval between injury and osteotomy was 20-245 days (median, 34.5 days). After minimally invasive osteotomy and placement of a semi-circular external fixator, the lengthening began on the 5th day. The proximal phalanx and metacarpal were lengthened by 0.5 mm every day, once every 12 hours. The thumb of the affected side was distracted to the middle of the distal phalanx of the healthy thumb, and the fixator was removed after the bone healed.

Results

The distraction time was 14-23 days, with an average of 18.8 days. The osteotomies were healed with healing time of 91-147 days (mean, 120.2 days). The total distraction length of the proximal phalanx and metacarpal was 1.40-2.25 cm, with an average of 1.86 cm; healing index was 51.0-72.2 days/cm, with an average of 64.9 days/cm. All patients were followed up 5-12 months (mean, 8.2 months). At last follow-up, the two-point discrimination was 5.3-8.5 mm with an average of 6.98 mm. According to the evaluation standard of the upper limb part of the Chinese Medical Association, the score was 10-14, with an average of 12.5. Among them, 4 cases were excellent and 2 cases were good, with an excellent and good rate of 100%. All patients were satisfied with the function and appearance of thumb after operation. The Quick Disabilities of Arm, Shoulder, and Hand (Quick-DASH) score was 2.3-9.1, with an average of 6.1.

Conclusion

The double osteotomy and lengthening of proximal phalanx and metacarpal with Ilizarov technique is an effective method for the treatment of thumb defects.

Current indications for abdominal-based flaps in hand and forearm reconstruction

Extensive soft tissue loss or injury of the hand and upper extremity is a challenging reconstructive problem traditionally treated with abdominal-based pedicled flaps. Options for coverage included the groin flap based on the superficial circumflex iliac artery, the Scarpa's fascia flap based on the superficial inferior epigastric artery, and the paraumbilical perforator flap from the deep inferior epigastric artery perforators. Despite the ability to provide consistent and pliable soft tissue coverage with ease of elevation, these flaps have several disadvantages including restriction of mobility, requirement for multiple procedures, bulkiness and patient discomfort. With the advent of microsurgery, pedicled regional flaps, and off-the-shelf skin substitutes, the applications for these flaps have narrowed. However several indications still remain. These include: patient and facility factors which deter microsurgery, the absence of recipient vessels after injury, prior surgical use of recipient vessels, the need to preserve major vessels for future reconstruction, and large multi-surface wounds requiring coverage. In this review we detail these indications and provide case examples for each.

Reconstruction of Traumatic Dorsal Loss of the Thumb: Four Different Surgical Approaches

BACKGROUND

This article outlines our methods for thumb reconstruction following dorsal skin loss injury located between the metacarpophalangeal joint (MPj) and the entire nail affecting skin, nail, tendon, and bone in different combinations but with intact sensate palmar skin.

METHODS

Between 1990 and 2015, 24 patients were treated for dorsal thumb defects using 4 different surgical techniques. Five cases of dorsal compound traumatic loss were reconstructed by custom-made dorsal great toe transfer. Four patients with dorsal skin and nail loss located at the distal phalanx level were covered with the homodigital flap with reverse flow vascularization. In 9 patients presenting skin defects between the MPj and the nail, reconstruction was achieved by means of the kite flap. Six cases suffered extensive dorsal skin loss, and reconstruction was performed using different types of radial forearm flaps (cutaneous, tendineocutaneous, osteocutaneous, and fascial).

RESULTS

Flap survival was obtained in all cases. No vascular complications occurred with free vascularized compound toe transfer.

CONCLUSIONS

Reconstruction of dorsal thumb defects is imperative and its approach is strictly correlated to type of defect, patient's requests, and flap alternatives. For defects with nail involvement, the free osteo-onychocutaneous flap harvested from the great toe provides the best aesthetic result in selected young and well-motivated patients. An alternative is represented by the dorsoulnar flap, when the defect is located distally, or the fascial pedicle radial forearm flap, for major dorsal thumb defects, in patients refusing microsurgical reconstruction. The kite flap still represents a feasible solution for medium-size defects with an intact nail.

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.

Technical Points of 5 Free Vascularized Flaps for the Hand Repairs

In this article, we present the experiences from Chinese microsurgeons on 5 less commonly used free vascularized flaps in hand reconstruction. In many units in China, these flaps have become the mainstays of treatment; they are routinely used for fingertip and thumb reconstruction. Their combined experience has demonstrated the reliability and versatility of these flaps for hand reconstruction, as well as their cosmetic value.

Secondary Thumb Reconstruction in a Mutilated Hand

The thumb plays an integral role in hand function. Traumatic amputation results in significant morbidity. With loss of the thumb, up to a 40% reduction in hand function may result. Thumb replantation must be attempted when possible. The goals of thumb reconstruction are to replicate normal function as closely as possible, minimize donor site morbidity, and expedite recovery. In the setting of a mutilated hand, the status of the remaining digits must be carefully assessed. Toe transfers, osteoplastic thumb reconstruction, and pollicization are commonly used. This article summarizes the indications and technical considerations in addressing the deficiencies after thumb amputation.

Recent Advances in Immediate Toe-to-Hand Transfer

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

Combined two foot flaps with iliac bone graft for reconstruction of the thumb

The purpose of this report was to retrospectively review the results of reconstruction of the thumb by use of combined two foot flaps with an iliac bone graft. From 2009 to 2014, nine patients with traumatic amputation of the thumb had their thumbs reconstructed. The two flaps were based on one pedicle. All flaps survived completely. Patients were followed for a mean of 15.6 months (range, 6-35 months). The appearance of the reconstructed thumb was comparable to a normal one, except for one thumb which required debulking. The appearance of the nail was satisfactory without deformity. The range of joint motion was satisfactory. The two point discrimination of the pulp ranged from 6 mm to >15 mm. The Michigan Hand Questionnaire outcome score was a mean of 76.2 ± 11.3 points and the Maryland foot rating score a mean of 94.8 ± 3.4 points. The combined two foot flaps with iliac bone graft might provide an option for the reconstruction of the thumb.

LEVEL OF EVIDENCE

III.

Immediate Great Toe Transfer for Thumb Reconstruction After Tumor Resection: Report of 3 Cases

BACKGROUND

Modern oncologic surgery aims not only to obtain tumor-free margins but also to spare or reconstruct limb function and preserve quality of life. A negative tumor margin in the digit generally requires amputation; therefore, function is preserved with reconstruction. We report results of simultaneous ablative tumor resection and reconstruction with a great toe transfer in patients requiring surgery for aggressive benign and malignant thumb tumors.

METHODS

Between 2000 and 2009, three patients with extensive soft tissue tumors of the distal thumb underwent amputation to obtain wide negative surgical margins. In each case, an immediate trimmed toe-to-thumb transfer was performed. Results, evaluated retrospectively, included a review of perioperative complications, donor-site morbidity, oncologic status, objective functional outcomes, and subjective patient satisfaction.

RESULTS

Three patients were found with either locally aggressive benign (n = 1) or malignant (n = 2) tumors of the thumb. All patients underwent immediate reconstruction after amputation through the base of the proximal phalanx for tumor eradication. No perioperative complications were encountered, and all toes survived. Full thumb opposition and protective sensation were achieved in all patients. All patients returned to their previous occupation without functional limitations. There is no local or distant tumor recurrence. Delayed wound healing at the ipsilateral foot donor site occurred in all 3 patients. Wet-to-dry dressing changes were successful in 2 patients, whereas the third patient required full-thickness skin grafting. All patients were satisfied with their reconstruction.

CONCLUSIONS

An immediate great toe-to-thumb transfer should be considered when thumb amputation is required to satisfy adequate oncologic margins. Such a transfer provides simultaneous restoration of digit length, position, sensation, and acceptable esthetics. This procedure is technically demanding and requires an experienced microsurgical team as well as appropriate patient counseling and consent before surgery.

Vascularized nail transfer from non-replantable digit: a case report

We report the case of a traumatic amputation by circular saw of the ring and small fingers, associated with middle finger nail matrix loss and tendon, bone and joint exposure. The replantation was not attempted with patient's consent. Since the nail unit from the ring finger was intact, we decided to harvest the ring finger nail unit for major finger reconstruction. Although the principle of vascularized transfer from a severely damaged finger is widely recognized and the vascularized nail transfer from toe is a relatively common procedure, there is no description of a vascularized nail transfer from a non-replantable digit in the literature.

Onycho-osteo-cutaneous defects of the thumb reconstructed by partial hallux transfer

PURPOSE

To present our experience in distal thumb amputations reconstructed by partial toe to hand transfers with special emphasis on manual workers.

METHODS

Twenty-five patients who experienced amputation of the thumb distal to the interphalangeal joint, excluding pure soft tissue losses, were included in the study. All but 2 were manual workers. Twenty were reconstructed within 2 weeks after injury. The other 5 were referred late. In all patients, the ipsilateral hallux was used as donor, based on the proper digital artery (18 cases), the intermetatarsal artery (6 cases), and the dorsalis pedis artery (1 case).

RESULTS

All transferred flaps survived. At a minimum follow-up of 1 year (range, 1-14 y), active range of motion at the interphalangeal joint was more than 55° in 23 patients. Two had an interphalangeal joint arthrodesis, 1 of them before referral. Pinch and grip were similar to the contralateral side. Two-point discrimination was normal in the dorsal oblique amputations and 7 to 11 mm in the rest. Patient satisfaction was high from a functional and aesthetic standpoint (9.5 out of 10 on a visual analog scale for both outcomes). All patients returned to work 2 to 4.5 months after the operation. Delayed donor site healing was noticed in 4 cases.

CONCLUSIONS

In contrast to classic teaching that recommends stump closure for cases of distal thumb amputation, we attained excellent results with partial toe transfer in manual workers. In our experience, the thumb can be restored to nearly normal with an acceptable donor site sequela. The best indication is for cases of dorsal oblique amputations, because thumb sensibility is unaffected, and for amputations where the germinal matrix is preserved, because nail regrowth occurs. Early transfer is strongly recommended.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Toe-to-hand transfer: evolving indications and relevant outcomes

Toe-to-hand transfer is indicated for many types of congenital and traumatic thumb absences. This review will highlight the applications of toe-to-hand transfer and their functional, aesthetic, and psychosocial outcomes. Despite its technical complexity, toe to hand reconstruction techniques can provide an elegant option to restore function for patients with difficult hand disabilities.

Presentation, microsurgical therapy, and clinical outcomes in three cases of expanding melanonychia of the nail unit in children

The management of expanding melanonychia in childhood is controversial. Here, we present three cases and discuss their operating indications and reconstruction. Between January 1, 1995 and December 31, 2007, one boy and two girls, were operated for expanding melanonychia, involving the thumb, index finger or the middle finger. They were 2, 4, and 7 years at the time of surgery. A complete resection of the nail plate was performed followed by a direct finger reconstruction using a free short-pedicle vascularized nail flap of the toe. Histology showed a junctional nevus in all cases. The follow-ups were after 2, 3, and 5 years and without any complications or recurrence. Regarding reconstruction, the mean Foucher and Leclère score were, respectively, 17 and 16 points. It is concluded that for expanding melanonychia, in case of doubt, an examination of the entire lesion is necessary. Reconstruction of the nail unit after wide excision with nail plate ablation can be performed using microsurgery as discussed below. However, new guidelines on shave biopsy can make this microsurgical procedure obsolete.

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.

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.