Paediatric toe-to-hand transfer: an assessment of outcomes from a single unit

From Simple to Complex: Preserving and Reconstructing the Traumatized Thumb

Traumatic thumb injuries significantly affect overall hand function and may result in considerable disability. Reconstructing the traumatized thumb requires a detailed preoperative assessment of the defect and evaluation of the patient's social history and medical comorbidities. Reconstructive techniques can be stratified by the level of thumb injury. The goals of thumb reconstruction are to restore length, stability, mobility, and sensibility. This article reviews reconstructive principles and operative techniques for reconstructing the traumatized thumb.

General Population and Surgeon Preferences for Pollicization Versus Toe-To-Thumb Transfer for Reconstruction of Traumatic Thumb Loss in Adults: An International, Multi-Center Survey Study

PURPOSE

Data objectively comparing outcomes following pollicization versus toe-to-thumb transfer for reconstruction after traumatic thumb amputation in adults remains sparse. Given that this decision is reliant on personal preference, it is important to understand the subjective nature of these preferences, particularly in the context of culture. The purpose of this study was to compare Eastern and Western societal and hand surgeon preferences for pollicization versus toe-to-thumb transfer for traumatic thumb reconstruction.

METHODS

Investigators from 6 international locations recruited local hand surgeons and members of the general population. Austria, Germany, the United States, and Spain were grouped as "Western" nations. China and India separately represented "Eastern" nations. Participants completed a questionnaire evaluating their personal preferences for pollicization and toe-to-thumb transfer. The questions posed to the general population and hand surgeons were identical. Demographic data were also collected.

RESULTS

When comparing the Western nations, China, and India, there was no difference in personal preferences within the general population for pollicization versus toe-to-thumb transfer. In contrast, most Indian hand surgeons favored toe-to-thumb transfer and most Western surgeons were uncertain about which procedure they would favor. Surgeons had more optimistic expectations regarding postoperative hand function, new thumb sensation, and hand appearance following pollicization than the general population. Similarly, for toe-to-thumb transfer, a greater proportion of surgeons predicted good-to-excellent function, sensation, and appearance.

CONCLUSIONS

There was no clear, observed "East" versus "West" difference in the general population's personal preferences for pollicization versus toe-to-thumb transfer among study participants. The members of the general population and hand surgeons had different outcome expectations.

CLINICAL RELEVANCE

Understanding how culture influences patient and hand surgeon preferences for pollicization versus toe-to-thumb transfer may help guide future decision-making for traumatic thumb reconstruction.

Long-term donor site outcome after second toe transfer for congenital hand differences

This study evaluates the long-term donor site outcomes after second toe transfers for congenital hand differences performed during childhood. In total, 25 toe transfers in 18 patients were followed up for a mean period of 17.4 years. We examined the patients clinically, radiologically and with a gait analysis system. Patient-reported outcome measures were collected. The patients were asymptomatic and there were no problematic clinical or radiological findings. Patients expressed high levels of satisfaction. The results were consistent, regardless of the resection level in the toe transfer or whether the operation was unilateral or bilateral. No postoperative complications or late reoperations on the foot were observed.Level of evidence IV.

Correction of symbrachydactyly: a systematic review of surgical options

Symbrachydactyly is a rare congenital malformation of the hand characterized by short or even absent fingers with or without syndactyly, mostly unilaterally present. The hand condition can vary from a small hand to only nubbins on the distal forearm. This study aims to systematically review the surgical management options for symbrachydactyly and compare functional and aesthetic outcomes.The review was performed according to the PRISMA guidelines. Literature was systematically assessed searching the Cochrane Library, PubMed, Embase, and PROSPERO databases up to January 1, 2023. Studies were identified using synonyms for 'symbrachydactyly' and 'treatment'. Inclusion criteria were the report of outcomes after surgical treatment of symbrachydactyly in humans. Studies were excluded if they were written in another language than English, German, or French. Case reports, letters to the editor, studies on animals, cadaveric, in vitro studies, biomechanical reports, surgical technique description, and papers discussing traumatic or oncologic cases were excluded.Twenty-four studies published were included with 539 patients (1037 digit corrections). Only one study included and compared two surgical techniques. The quality of the included studies was assessed using the Modified Coleman Methodology Score and ranged from 25 to 47. The range of motion was the main reported outcome and demonstrated modest results in all surgical techniques. The report on aesthetics of the hand was limited in non-vascularized transfers to 2/8 studies and in vascularized transfers to 5/8 studies, both reporting satisfactory results. On average, there was a foot donor site complication rate of 22% in non-vascularized transfers, compared to 2% in vascularized transfers. The hand-related complication rate of 54% was much higher in the vascularized group than in the non-vascularized transfer with 16%.No uniform strategy to surgically improve symbrachydactyly exists. All discussed techniques show limited functional improvement with considerable complication rates, with the vascularized transfer showing relative high hand-related complications and the non-vascularized transfer showing relative high foot-related complications.There were no high-quality studies, and due to a lack of comparing studies, the data could only be analysed qualitatively. Systematic assessment of studies showed insufficient evidence to determine superiority of any procedure to treat symbrachydactyly due to inadequate study designs and comparative studies. This systematic review was registered at the National Institute for Health Research PROSPERO International Prospective Register of Systematic Reviews number: CRD42020153590 and received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.Level of evidenceI.Systematic review registrationPROSPERO CRD42020153590.

A systematic review of the use of psychological assessment tools in congenital upper limb anomaly management

STUDY DESIGN

This study is a systematic review.

INTRODUCTION

Congenital upper limb anomalies (CULAs) are often associated with psychosocial difficulties including negative body image, low self-esteem, and withdrawal from social activities.

PURPOSE OF THE STUDY

The purpose of the study was to identify, describe, and evaluate all published psychosocial assessment tools used in the assessment and management of CULAs, to direct the use of these tools in clinical practice, and to identify areas requiring development.

METHODS

A systematic search of Medline, EMBASE, Pubmed, and PsychInfo databases was performed. In total, 23 studies were included for analysis. Data extracted included study and population characteristics, psychosocial measures utilized, psychosocial outcomes reported, and the reliability and validity of measures.

RESULTS

Seventeen patient-reported measures were identified. The most commonly used tool was a Likert scale (n =7) with satisfaction with appearance and function, the most commonly evaluated outcome (n = 18). Other evaluated domains included quality of life or psychosocial functioning (n = 9), self-image (n = 2), and psychological well-being (n = 5).

DISCUSSION AND CONCLUSIONS

There is no well-established, validated assessment tool in regular use to effectively address psychosocial outcomes for children with CULAs. Although the majority of children born with a CULA appear to adjust well, this is by no means the case for all children. There is a need for routine psychosocial evaluation preoperatively and postoperatively with long-term follow-up data to help direct patient-orientated management. A clear understanding of these, and how to measure them, is needed to help for a patient-centred, multidisciplinary, evidence-driven approach to CULA management.

Unique Techniques or Approaches in Microvascular and Microlymphatic Surgery

Several methods can be used for identifying tissues for transfer in donor-site-depleted patients. A fillet flap can be temporarily stored in other parts of the body and transferred back to the site of tissue defect, including covering the amputated stump of the lower extremity. Human arm transplant is rare and has some unique concerns for the surgery and postsurgical treatment. Cosmetics of the narrow neck of transferred second toes can be improved with insertion of a flap. Lymphedema of the breast after cancer treatment can be diagnosed with several currently available imaging techniques and treated surgically with lymphaticovenous anastomosis.

Digital Transfer for Hand Reconstruction in Cleft Hand and Foot Differences

BACKGROUND

 Digital transfer for hand reconstruction in children with cleft hand and foot differences present unique challenges with anomalous anatomy and rare opportunities to dramatically improve function of one- or two-digit hands.

METHODS

 Medical records were reviewed for patients with cleft hand and foot treated at two pediatric institutions between 1996 and 2018. Hospital records, clinical photographs, radiographs, and alginate molds were available on all patients. Patient characteristics, indications for transfer, associated syndromes, donor and recipient anatomy, and complications were examined.

RESULTS

 Twenty digital transfers were identified in 16 patients. The mean age at time of transfer was 6 years (range: 3-18 years). Associated syndromes in this study included ectrodactyly ectodermal dysplasia clefting (EEC) syndrome and Goltz's syndrome. Recipient sites included the thumb (n = 17) and index ray (n = 3) in 10 hands with monodactyly, 6 hands with a two-digit ulnar syndactyly, and 3 hands with central deficiency and associated polydactyly or other anomalies. Donor sites included the great toe (n = 7), fifth toe (n = 9), great toe polydactyly (n = 2), thumb polydactyly (n = 1), and second toe (n = 1). All transfers survived. Revisions included tenolysis (n = 2), repeat fixation for nonunion or malunion (n = 2), and fusion for instability (n = 3).

CONCLUSION

 Digital transfer in cleft hand and foot patients is a functional endeavor. The transferred digits provide sensation, mobility, and stability for opposition. Technically challenging due to small structures and atypical anatomy, these rare cases represent unique opportunities to improve function and appearance in the pediatric hand. This is a therapeutic study and reflects level of evidence IV.

Toe-to-Hand Transfer in an Ulnar Hemimelia Patient: A Case Report

Ulnar hemimelia is a rare congenital deformity. The severity of the deformity increases with the number of fingers that are absent. Clearly, grip function is impossible with a mono-finger hand. Here, we present a case report of a patient with bilateral ulnar hemimelia that included the absence of radial fingers and also deformity in the toes of his left foot. A toe-to-hand transfer was performed successfully to help the patient gain grip function. Both the patient and the parents were very pleased with the result. To our knowledge, this is the first case report of a patient with ulnar hemimelia and absent radial fingers who was treated with a toe-to-hand transfer.The most important factors in a successful surgery are careful preoperative planning and microsurgical expertise. Angiography is the key to careful planning, and physiotherapy should also be done to increase the patient's functions. The psychological well-being of patients and parents will be positively affected after a successful surgery.

Combination free foot flaps for digit reconstruction: A retrospective analysis of 37 cases

Combination foot flaps for digit reconstruction was previously introduced by our group as an alternative method for toe-to-hand transfer. The aim of this study was to analyze our experience with the combination foot flaps and to present the surgical refinements that were introduced. A prospective study was conducted including all combination foot flaps performed at our hospital since September 2009. Surgical refinements that were introduced during this study included island flap for repair of toenail donor site and the use of Z-plasty. The median operation duration was 6.7 hours (range 3.5-13 h). Among 74 flaps, partial necrosis occurred in three flaps (4.1%); two palmar flaps (2.7%) were bulky. Among 37 cases of reconstructed digits, contracture of the first web occurred in one case (1.4%). All the patients were able to walk well and did not complain of any pain or cold intolerance. Wound dehiscence of donor site was observed in three patients (8.1%). Toenail deformity occurred in one case (2.7%). The combination foot flap is a reliable option for digit reconstruction with minimal donor site complications.

Vascularized second metatarsophalangeal joint transfer for radial deficiency - an update

Vascularized second metatarsophalangeal joint transfer offers a possibility to reconstruct the radial support which is lacking in radial dysplasia. Our experience from 1987 to 2017 with 34 congenital radial club hand reconstructions have allowed a possibility for long-term evaluation of the method. Compared with conventional methods, second metatarsophalangeal joint transfer results in better wrist mobility and does not restrict typical ulnar growth. The balance of the wrist remains good until age 11. Thereafter, the growth of the vascularized bone graft transfer matches only partially the distal ulnar growth in adolescence, resulting in mild recurrence of radial deviation. A new option to create a two-bone forearm in selected Bayne-Klug Type III radial dysplasia cases will allow a relatively good pro-supination ability. Potentially, a proximal fibular epiphyseal transfer could be a future solution. Currently, a safe harvest of the proximal fibula at childhood remains controversial.

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.