Long-term functional results of microvascular toe-to-thumb reconstruction

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.

A Systematic Review of the Outcomes of Microsurgical Toe Transfer for Metacarpal and Metacarpal-Like Hand Deformity

Background: Thumb and multiple finger amputations may result in a metacarpal and a metacarpal-like hand deformity. Toe-to-hand transfer is a recognised treatment strategy for this deformity but has risks and is resource intensive. The aim of this study is to conduct a systematic review of the outcomes of toe-to-hand transfer for traumatic metacarpal and metacarpal-like hand deformity in adult patients. Methods: Multi-database searching with index and free text terms, duplicate standardised screening and extraction, and quality assessment was performed. The inclusion and exclusion criteria were prespecified. We included any randomised controlled trials, cohort studies, case-control studies, as well as interrupted time series, before and after intervention studies. Results: Screening of 548 articles yielded 20 studies eligible that included 19 retrospective observational studies and one before and after intervention study. A total of 171 patients underwent 274 toe transfers for metacarpal and metacarpal-like hand deformity. No study compared toe-transfer to a control group or to a prosthesis. The before and after intervention study demonstrated significant improvement in activities of daily living, work, aesthetics and satisfaction. Additionally, no significant donor site morbidity occurred in the heterogenous sample. Outcomes from remaining studies at risk of bias suggest that those with a lesser severity of injury and at least two toe transfers score higher in functional tests and scoring systems. Conclusions: There is limited confidence in the effectiveness of toe transfer for metacarpal and metacarpal-like hand deformity. The available evidence indicates that toe transfer(s) may restore acceptable function permitting activities of daily living, return to original or sedentary occupation and affords satisfaction. Level of Evidence: Level III (Therapeutic).

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

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

The Modified Vilkki Procedure: Vascularized Metatarsophalangeal Joint Transfer to Reconstruct a Full-Length Radius in Type III Radial Hypoplasia

Radial longitudinal deficiency is a spectrum of deformity ranging from thumb hypoplasia to a shortened or absent radius. Traditional treatments are hindered by recurrent deformity and disruption of future forearm growth. These deficiencies can be addressed by a Vilkki procedure in which a free second toe metatarsophalangeal joint is used to restore a radial column and provide viable physes for continued forearm growth. A classic Vilkki procedure positions the proximal toe metacarpal on the native ulna to create a Y-shaped one-bone forearm. We report a case of a modified Vilkki procedure in which a 2-bone forearm is created using the proximal toe metacarpal to reconstruct the entire radius. In patients with type III radial longitudinal deficiency with suitable residual radius length, the modified Vilkki procedure can allow reconstruction of a 2-bone forearm. This affords the patient correction of the pathoanatomy and the potential for balanced growth and pronosupination.

Patient-Reported Outcome Measures for Toe-to-Hand Transfer: A Prospective Longitudinal Study

BACKGROUND

Patient-reported outcome measures are an important metric in evaluating treatment efficacy of reconstructive surgery. Toe-to-hand transfer can restore vital prehensile function; however, this surgery is complex, extensive rehabilitation is required, and there are concerns about donor-site morbidity. This study longitudinally explores the benefits of this procedure, from the patient's perspective, using patient-reported outcome measures.

METHODS

Twenty-three patients who underwent free toe-to-hand transfers from 2012 to 2015 were evaluated preoperatively and postoperatively using the following validated questionnaires: the Michigan Hand Outcomes Questionnaire, the 36-Item Short-Form Health Survey, and the Lower Limb Outcomes Questionnaire. Subgroup analysis was performed between dominant and nondominant reconstructed hands.

RESULTS

Mechanism of injury was crush in 83 percent; the remainder sustained cutting, avulsion, and burn injuries. Thirty-four toes were transferred: nine great toes, 20 second toes, and five third toes. Michigan Hand Outcomes Questionnaire results showed significant improvement in overall activities of daily living, work, aesthetics, and patient satisfaction (p < 0.05). The results of the 36-Item Short-Form Health Survey showed significant improvements in physical and emotional roles (p < 0.05). The Lower Limb Outcomes Questionnaire showed no deterioration of foot function (p = 0.55). Subgroup analysis showed significant improvement in patient-reported outcome measures for patients undergoing dominant hand reconstruction but no difference between thumb reconstruction and finger-only reconstruction.

CONCLUSIONS

Patient-reported outcome measures demonstrate the significant utility of toe-to-hand transfer procedures in both functional and psychosocial domains in that there are relatively greater benefits in reconstructing the dominant hand, and that donor-site morbidity is well tolerated.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Distal Finger Reconstruction by Bilateral Lateral Hallux Osteo-onychocutaneous Free Flap

OBJECTIVE

In this report, we present our experience on the use of bilateral lateral hallux osteo-onychocutaneous free flaps for reconstruction of distal finger and the aesthetic and functional results of this technique in a series of cases.

PATIENTS AND METHODS

From February 2005 to May 2015, 7 patients underwent finger reconstruction distal to the distal interphalangeal joint using the bilateral lateral hallux osteo-onychocutaneous free flaps. The mean age was 29.3 years (range, 24-33 years). The lateral hallux osteo-onychocutaneous flaps were harvested from bilateral donor sites. The size of each flap was designed based on the size of half distal finger defect. The lateral hallux osteo-onychocutaneous free flaps from both donor sites were combined to reconstruct the distal finger. More than 50% of hallux nail was preserved in each of donor sites, which was covered with a local flap.

RESULTS

All flaps used for reconstruction survived without complications after surgery. The average length of follow-up was 93.4 months (range, 16-163 months). All reconstructed distal fingers showed good aesthetic appearance, except one that underwent a secondary debulking procedure. The average total active motion of the finger was 215.7 degrees (range, 200-230 degrees). Neither pain nor numbness sensation in the reconstructed fingers was complained by the patients. The donor site morbidity was minimal. All patients had pain-free and good function outcome in both feet.

CONCLUSIONS

The use of the bilateral lateral hallux osteo-onychocutaneous free flaps may provide an option for distal finger reconstruction with satisfactory function and anesthetic outcomes with minimal hallux donor site morbidity.

The Biomechanical Impact of Digital Loss and Fusion Following Trauma: Setting the Patient up for Success

Surgeons managing mutilating hand injures are faced with difficult decisions between attempting to salvage remaining or injured digits or proceeding to amputation and fusion. Through application of a basic understanding of hand biomechanics, the surgeon may more accurately predict what motion and function can best be salvaged. This article provides an explanation of how amputation, fusion, and tendon loss can affect postoperative hand motion. The surgeon can use these concepts in planning the reconstruction or preparing the foundation for secondary reconstructive procedures to achieve the highest functional outcome for the patient.

Long-term effects of toe transfers on the donor feet

The purpose of this study was to assess the long-term consequences to the donor site of microvascular transfer of one or two toes. This was achieved retrospectively by patient-reported, clinician-based and functional testing. Weight-bearing radiographs were taken of both feet. Seventy-four patients (80 feet, 84 transferred toes) participated in this study. After a median of 16 years follow-up, most patients reported no or only minor complaints concerning the donor site. Cold intolerance and pain during exertion were the most commonly reported complaints. According to the two functional scores used, 92% of patients reported no or minor complaint and 83% of patients received a good result at the donor feet. Maintaining first ray alignment and avoiding early postoperative complications predicted a better outcome. Even though donor site ramifications should be expected after microvascular transfer of toes, patient satisfaction remains high.

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.

Reconstruction of the thumb amputation at the carpometacarpal joint level by groin flap and second toe transfer

INTRODUCTION

Traumatic loss of thumb at the carpometacarpal (CMC) joint level is very disabling to an individual. Pollicisation is the recommended technique of reconstruction for loss of thumb at this level. On occasions, injury to the rest of the hand or amputation of additional fingers may make pollicisation an impossible option. Microsurgical transfer of second toe is an option in such situations. Although many large series of toe transfers are available in the literature, no series deals exclusively with this subset of patients.

MATERIALS AND METHODS

Eight patients who had amputation of the thumb at or proximal to the CMC joint level were reconstructed by second toe transfer by us in the period 2002-2011. All had preliminary groin flap cover in the area of the thumb during the acute stage of treatment. Second toe with the metatarsal was transferred for thumb reconstruction after a mean duration of 3 months after flap cover. Patients were assessed for their ability to pinch, hold large objects and opposition achieved by Kapandji score. Average follow up is 4 years and 6 months with a minimum of 1 year.

RESULTS

All toe transfers survived. They reached their maximum functional potential by 1 year. All patients actively used the reconstructed thumb for day to day activities. Pinch was possible in all patients except two patients who did not have any fingers. Six of them registered grip strength of at least 50% of the opposite hand. When fingers were present, opposition was possible in all patients with Kapandji scores ranging from 5 to 8. Extent of usage was less in patients who did not have good function in other fingers.

CONCLUSION

Second toe transfer is a viable option for reconstruction of thumb loss at or proximal to the CMC joint level. Proper planning of the preliminary flap cover determines the length of the thumb reconstruction. Strategic position of the transferred toe of adequate length and the functional status of the other fingers are important determinants of functional outcome.

Bilateral microvascular second toe transfer for bilateral post-traumatic thumb amputation

In bilateral thumb amputations, the functional impairment is serious and every attempt should be made to reconstruct the thumb. We report a case of bilateral post traumatic thumb amputation, reconstructed with bilateral second toe transfer. Only two such cases have been reported in literature so far. Though there are various modalities for the reconstruction of thumb, microvascular toe transfer has its own merits. The convalescent period is minimal with excellent function. It is bilaterally symmetric and aesthetically superior to the osteoplastic reconstruction. The technical details are discussed, and the long term functional and aesthetic results are presented.