Thumb-Sparing Surgery for Digital Papillary Adenocarcinoma: A Case Report.

Digital papillary adenocarcinoma (DPA) is a rare eccrine sweat gland tumor that often appears as a solitary, non-painful, gradually enlarging mass. Clinically, DPA presents considerable challenges due to its high likelihood of recurrence and its tendency to spread to the lymph nodes and lungs. This case report focuses on the surgical treatment of a unique case of DPA located on the dorsal thumb in a 46-year-old male. The patient initially underwent wide local excision with temporary wound coverage, and once final histopathological findings confirmed negative margins, a second procedure consisting of thumb interphalangeal joint fusion and first dorsal metacarpal artery flap coverage was performed. Eighteen months later, the patient continued to work in landscaping, performing the physically demanding tasks required by the job. This case demonstrates the feasibility of thumb preservation in the setting of soft tissue malignancy once negative margins are obtained.

Advances in Pediatric Toe Transfers.

Microsurgery is undoubtedly the pinnacle of hand surgery. Significant advancement in recent years has stretched the indications for toe-to-hand transfer in both acquired and congenital hand defects to restore function, esthetics, and motion, with minimal morbidity to the donor site. There is no one fixed microsurgical transfer technique but a surgeon's versatility and innovation in using what one could spare because each case is unique. Esthetic refinements and reducing donor site morbidities have taken a front seat in recent years. We present a few cases to put forward the senior author's preferred techniques with this objective in mind.

An alternative method to reconstruct grade-3 hypoplastic thumb by hemi-metacarpal transfer.

We designed a new method using hemi-longitudinal second metacarpal bone to reconstruct grade-3 hypoplastic thumbs. Seven patients were treated in two stages. In the first stage, the second metacarpal was split longitudinally and transferred to reconstruct the first metacarpal. In the second stage, opponensplasty was performed by transferring the FDS tendon. Bone union was achieved in all cases. All patients could oppose to their middle finger at least. They managed to do daily activities such as writing, eating, using smartphones and so on. This is a useful procedure to preserve a 5-digit hand with good function in treating grade-3 hypoplastic thumbs, with no harm to the foot and no need for vascular anastomosis. LEVEL OF EVIDENCE: IV.

Temporal Fascia Free Flap for Thumb Coverage in Electrical Burn Injuries: A Case Series Analysis With DASH Score Outcomes Evaluation.

Electrical burns pose unique challenges in reconstructive surgery due to the extensive tissue damage they cause. The thumb is particularly susceptible to electrical burns, leading to severe functional impairment. This case series introduces the use of the temporal fascia free flap for thumb coverage in patients with electrical burn injuries. The study aims to assess the functional outcomes of this approach using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Six male patients underwent thumb reconstruction using temporal fascia free flaps following electrical burn injuries. The extent of the injury was assessed, and necrotic tissue was debrided. Functional outcomes were evaluated using the DASH questionnaire 6 months postoperation. All procedures were conducted in accordance with ethical guidelines, and informed consent was obtained from all patients. All patients achieved successful transplants using temporal fascia free flaps. The average DASH score at the 6-month follow-up indicated satisfactory functional recovery. Patients reported improvements in thumb mobility and functionality, and the cosmetic appearance of the thumb was acceptable. The appearance of the scar in the donor area was well-received. The temporal fascia free flap proved to be an effective method for thumb reconstruction following electrical burn injuries. Its thin and flexible nature allows for optimal contouring and improved range of motion. Although one case of partial flap loss was observed, overall functional and aesthetic outcomes were satisfactory. Further research with larger sample sizes is warranted to optimize surgical techniques and postoperative care for better outcomes.

A Systematic Review and Illustrative Case Presentation of Low-Grade Myofibroblastic Sarcoma (LGMS) of the Extremities.

INTRODUCTION: Low-grade myofibroblastic sarcoma (LGMS) is a rare tumor entity which occurs in the subcutaneous and deep soft tissues; it is less common in the bone with a predilection for the extremities and the head and neck region. As confirming the diagnosis is difficult and treatment strategies are not standardized, we aimed to identify patient and tumor characteristics, and to summarize treatment strategies and their clinical outcomes to guide surgeons. METHODS: Included were full articles reporting patients with histology of LGMS in the extremities, excluding tumors of the trunk. All patients underwent surgery but with different extend, from marginal to wide resection. Included studies should inform about local recurrence, metastasis, or evidence of disease, depending on the surgical treatment. We conducted a structured search using MEDLINE (via PubMed), Web of Science, EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL) to identify studies on low-grade myofibroblastic sarcoma of the extremities. Study designs like randomized controlled trials, systematic reviews, prospective trials, retrospective studies, and case reports were included. Prospective studies and comparative studies were not available at all. Therefore, meta-analysis was not possible and statistical analysis was purely descriptive. RESULTS: Of the 789 studies identified from our initial search, 17 studies including 59 cases reported LGMS of the extremities with the surgical treatment and clinical outcome and were therefore analyzed. In addition, we present the rare case and surgical management of a 28-year-old male patient with residual LGMS of the thumb after an initial incomplete resection. The current literature suggests that a wide excision with R0 margins should be considered the standard treatment for LGMS. In cases where surgery leads to significant functional impairment, individual options like free tissue transfer from a donor site have to be considered. Therefore, we also present an illustrative case. For all selected case series and case reports, a high risk of confounding, selection bias, information bias, and reporting bias must be anticipated. Nevertheless, this systematic review provides a comprehensive overview on surgical treatment and clinical outcomes in LGMS surgery of the extremities.

On-top-plasty reconstruction for thumb triplication.

Thumb triplication is a very rare pattern of radial polydactyly that presents as a more complicated form of thumb. Because of its morphological complexity, treatment often requires surgical ingenuity in addition to the conventional surgical treatment algorithms for duplication. We report the case of thumb triplication on the right hand of a 17-month-old boy. We performed on-top-plasty of the ulnar thumb over the intermediate thumb, and achieved a functional and aesthetic thumb. The technique of on-top-plasty is effective for finger reconstruction that maximizes the use of limited tissue and is widely used for treating hand trauma and congenital hand anomalies. In the present case, on-top-plasty contributed most effectively to creating a sufficiently sized thumb, achieving interphalangeal optimization by joining the extra middle phalanx with the proximal phalanx, and securing the first web space by moving the ulnar thumb laterally.

Forty-Year Follow-Up After Great Toe-to-Thumb Transfer: A Literature Review.

The thumb is a crucial part of the hand, and traumatic thumb amputation is a devastating injury that significantly diminishes hand function. In situations in which replantation is not possible, great toe-to-thumb transfer is a well-established option for reconstruction. Although most studies describe excellent functional outcomes and patient satisfaction, there is a paucity of literature presenting long-term follow-up to determine whether these outcomes are maintained. In this case report, we present a case of great toe-to-thumb transfer performed 40 years ago and evaluate outcomes using validated questionnaires and standardized examination maneuvers. Our results highlight sustained patient satisfaction and excellent functional outcomes decades after the initial reconstruction.

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.

Nonvascularized Iliac Crest Bone Graft for Reconstruction of the First Metacarpal in Type IIIB Thumb Hypoplasia: A Radiographic Follow-Up Study.

PURPOSE: To present a radiographic follow-up study of the use of a nonvascularized iliac crest bone graft as a treatment for modified Blauth type IIIB thumb hypoplasia. METHODS: From January 2015 to December 2019, nonvascularized iliac crest bone grafts were used to reconstruct the first metacarpal in 23 cases with type IIIB thumbs. The average follow-up duration was 1.9 years (range 1.0-3.9 years). We evaluated the patients' serial x-rays and measured the width and length changes of the reconstructed first metacarpals. RESULTS: Survival of the graft, judged radiographically, was achieved in 20 cases (20/23, 87%), with an average reduction of 33% in the width of the graft. Shortening of the graft (average 2.3 mm, range 0.1-5.6 mm) was noted in 11 of the 20 cases, and an increase in the length of the graft (average 4.2 mm, range 0.7-8.6 mm) was observed in the other 9. Bone graft failure (3/23, 13%) occurred in 3 cases because of significant bone resorption. CONCLUSIONS: For type IIIB thumb hypoplasia, a nonvascularized iliac crest bone graft was a feasible method to reconstruct the first metacarpal, with a 13% risk of graft failure, 33% average reduction in graft width, and 55% reduction in graft length. However, in cultures that value the preservation of a 5-digit hand, this technique may provide an alternative to excision with index pollicization. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Surgical Technique and Outcomes of Reconstruction for Blauth Type III Thumb Hypoplasia.

BACKGROUND: Historically, amputation and pollicization has been the recommended surgical treatment for Blauth type III hypoplastic thumbs. However, due to aesthetic objections or cultural preferences, some parents seek out alternative surgical options. The present study describes a nontraditional technique that preserves and augments the hypoplastic thumb. METHODS: Patient charts were retrospectively reviewed to identify patients with Blauth type III hypoplastic thumbs who underwent thumb reconstruction at our institution from 2008 to 2018. The reconstruction procedure involved toe phalanx transfer, staged tendon transfers, and lengthening as needed. Motion was assessed categorically as ability to flex, extend, or oppose the thumb. Functionality was assessed as ability to pinch and grasp with the surgical hand. Patient- or parent-reported improvement in thumb function was also recorded. RESULTS: Of the 13 patients, 100% could flex, extend, and oppose the thumb to some degree. Eleven patients (85%) had functional one-handed grasp, and 9 (69%) had a functional pinch. Eleven patients (85%) reported no functional limitations of the operative hand. Thirteen patients (100%) reported improvement in hand function after surgery as compared to pre-operatively. There were 2 minor complications (15%), both of which resolved after intervention. No patients experienced donor-site morbidity. CONCLUSIONS: Reconstruction of Blauth III thumbs is a nontraditional technique that allows for digit retention by salvaging the hypoplastic thumb. In the present study, the majority of patients had functional thumbs and all reported postoperative improvement. Overall, our results suggest that reconstruction is a viable surgical option for Blauth III hypoplastic thumbs.

Reverse homodigital dorsal wraparound flap for reconstruction of distal thumb.

Reconstruction of degloving injury or amputation of distal thumb with no indication of replantation has always been a challenging problem for hand surgeons. In this study, a reverse homodigital dorsal wraparound flap innervated by the dorsal digital nerve was devised to repair degloving injury or amputation of distal thumb in 20 consecutive cases. In nine cases of thumb amputation, we skeletonized the phalanxes of the amputated part as a free cortical bone with Kirschner wires. All flaps survived uneventfully. The radiographs showed bone healing in all the patients of thumb amputation within 6 weeks postoperatively. At final follow-up, the appearance of the reconstructed thumb was acceptable and flap sensation and range of joint motion were satisfactory. This flap is a simple and reliable alternative method for degloving injury or amputation of distal thumb when replantation is impossible and patients refuse to donate tissues from toes. Type of study/level of evidence Therapeutic IV.

Thumb reconstruction after radical tumor resection using free osteocutaneous lateral arm flap with secondary humerus fracture-a case report.

INTRODUCTION: Malignant diseases with infiltration of bony structures in the area of the phalanges or metacarpals require either amputation or complex reconstruction. The decision for reconstruction means to restore length, mobility, sensibility, stability as well as aesthetics. METHODS: We present a case of complex first ray reconstruction of the left hand using a free osteocutaneous lateral arm flap from the ipsilateral side. The reconstruction was performed after radical resection of an exulcerated squamous cell carcinoma, including the first metacarpal bone, trapezium, partial trapezoid and distal scaphoid as well as partial resection of the extensor pollicis longus, extensor pollicis brevis, abductor pollicis longus and flexor carpi radialis tendons. The osteosynthetic restoration was achieved distally by a double wire cerclage and a proximally by temporary K-wire suspension. Moreover, to reconstruct the extensor pollicis longus tendon the ipsilateral palmaris longus tendon was harvested and used. Postoperatively, a secondary humerus fracture occurred, which was initially attended by plate osteosynthesis. The fracture showed delayed healing, which was treated by re-plating and autologous cancellous bone. RESULTS: 12 months postoperatively, the patient showed an excellent outcome with length preservation and good range of motion, sensibility, stability and aesthetic of the thumb. Furthermore, the quarterly tumor aftercare showed no evidence of recurrence. CONCLUSION: This case report showed that the free osteocutaneous lateral arm flap is a reliable solution for the reconstruction of the first ray with a great functional and aesthetic outcome. To prevent a secondary humerus fracture, a preventive plate osteosynthesis simultaneous with the osteocutaneous flap elevation should be considered.

The "Domino Flaps" Concept: Functional Composite Reconstruction for Traumatic Transmetacarpal Thumb Amputation.

Complex transmetacarpal thumb amputation remains a challenging reconstructive injury. Optimal reconstructive options aim to achieve a neo-thumb with optimal length, sensitivity, stability, and an aesthetically functional result. In cases when immediate replantation of the amputated digit is not possible, a temporary ectopic replantation with staged reconstruction can be deployed. We report our experience of a complex transmetacarpal thumb amputation managed with a staged "domino flap" concept. The first stage involved an ectopic replantation of the amputated digit with a second stage replantation 3 weeks later. Domino flap refers to the requirement of a further reconstruction due to the defect at the donor sites. In this case, the replant is accompanied by 2 domino flap reconstructions with the dorsalis pedis composite free flap to reconstruct the first metatarsal and an anterior tibial artery propeller perforator flap to reconstruct the composite flap donor site.

Mid-Term Results of the First Dorsal Metacarpal Artery Flap for Thumb Defects.

Background: The thumb plays an important role in the function of the hand. Sensate reconstruction of the pulp is important in restoring function to the thumb. The aim of this study is to present outcomes of a sensate islanded first dorsal metacarpal artery (FDMA) flap used for the reconstruction of skin defects of the thumb. Methods: Patients who had a FDMA flap reconstruction of thumb pulp defects in the orthopaedics and traumatology clinic of affiliated hospital were included in the study. This included eight thumbs of eight patients. The range of motion, sensation and cosmetic satisfaction in the donor and recipient areas were evaluated at a minimum of 2-year follow-up. Results: There were no partial or complete flap failures. The mean static 2-point discrimination was 15 mm and the mean Semmes-Weinstein monofilament test score was 3.93. Cortical re-orientation was observed in 65% of patients. Near normal range of motion and Kapandji scores were regained in all patients. Conclusions: Excellent motion and sensory outcomes were obtained following the FDMA flap reconstruction of thumb pulp defects. The donor morbidity of the flap is minimal, and this flap can be considered as one of the primary options for reconstruction of thumb pulp defects. Level of Evidence: Level V (Therapeutic).

Index pollicization: an evolution of ideas and techniques from a paediatric orthopaedic institution.

Pollicization has been a very successful procedure in the treatment of specific types of hypoplastic thumb. Although much has remained the same since early descriptions of the procedure in the 1800s and 1900s, refinements over the years have made it safer and more predictable. Over the years at our institution we have studied, modified and refined our incisions to produce a new thumb that is aesthetically pleasing with excellent function. We present our technique for pollicization along with pearls and pitfalls we have discovered.

Secondary Thumb Reconstruction via Ectopic Banking of Bony Phalanges From a Nonreplantable Amputated Thumb: A Follow-Up Study.

PURPOSE: This study aimed to evaluate the radiological and functional results of secondary thumb reconstruction via ectopic banking of bony phalanges from a nonreplantable amputated thumb. METHODS: Thumb reconstruction was performed using the bony phalanges from a nonreplantable amputated thumb that were ectopically banked in a subcutaneous pocket. A wraparound flap was harvested from the ipsilateral great toe and wrapped around the bone graft. After surgery, the results were assessed in terms of infection, range of motion, bone union of the graft, and signs of osseous resorption of the reconstructed thumb. RESULTS: Fifteen patients underwent secondary thumb reconstruction using this technique between January 2003 and October 2018. Ten patients were followed up for at least 6 months (6 months to 9 years) and were included in this study. All wraparound flap transfers were viable. No bone graft infection was observed. In the 6 cases in whom the interphalangeal joint was not fused, the interphalangeal joint motion ranged from 5° to 60° with an average of 35.0° ± 15.1°. The metacarpophalangeal joint motion ranged from 5° to 66°, with an average range of motion of 48.2° ± 23.6° for the cases in whom the joint was not fused. In 8 of the 10 patients, the time of bone ectopic banking was within 10 days. In these patients, bone union with no osseous atrophy was observed. In 2 patients whose phalanx was banked for more than a month, different degrees of bone resorption of the grafted phalanx were evident after transplantation, although no further treatment was required. CONCLUSIONS: Bony phalanges from a nonreplantable amputated thumb can be ectopically banked and used for secondary reconstruction of the thumb. The duration of banking before thumb reconstruction should be no more than 2 weeks. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Thumb fingertip injuries reconstruction using a dorsoulnar flap of the thumb combined with relay V-Y flaps for donor site repair.

PURPOSE: To assess the clinical value and feasibility of the dorsoulnar flap of the thumb combined with relay V-Y flaps for reconstruction of the thumb fingertip injuries. METHODS: In this retrospective study, we retrospectively reviewed 20 patients (13 men, 7 women; June 2014-June 2016) with thumb fingertip defects who underwent reconstructive procedures with transfer of the dorsoulnar flap of the thumb. The average size of the defects ranged from 1.8 cm × 2.0 cm to 2.0 cm × 3.0 cm, whereas the reconstructed dorsoulnar flap of the thumb ranged in size from 2.0 cm × 2.2 cm to 2.2 cm × 3.0 cm. A V-Y flap was used to repair the donor site at the same time. Sensation within the reconstructed thumb, the aesthetic appearance of both the donor and recipient sites, functional recovery, and return-to-work (RTW) time were measured. RESULTS: All 40 flaps survived without necrosis. The follow-up period ranged from 6 to 24 months. There were no complications reported. The mean static two-point discrimination values at the reconstructed thumb fingertip and donor site were 8.5 mm (range 8-10 mm) and 12.5 mm (range 12-14 mm), respectively. The average visual analog scores for the aesthetic appearance of the recipient and donor sites were 8.4 (range 8-9.5) and 9.6 (range 9-10), respectively. The average Michigan Hand Outcome Questionnaire score for the reconstructed hand was 9.4 (range 6-16). The average RTW time was 9.8 weeks (range 6-13 weeks). All patients were satisfied with the aesthetic outcome. CONCLUSION: The dorsoulnar flap of the thumb is an ideal alternative for reconstruction of the thumb fingertip injuries, and a V-Y flap was suitable for repairing the donor site with a reduced incidence of complications.

Littler Neurovascular Island Flap in the Loss of Pulp Substance of the Thumb.

Q1. How can this defective soft tissue be covered? Q2. What are the surgical requirements and postoperative instructions? Q3. What indicators are used to assess the sensitivity of the flap? Q4. How is the impact of this type of flap on the patient's daily life evaluated?

A Comparison of Outcomes of Reconstruction of Palmar versus Dorsal Defects of the Thumb Using a First Dorsal Metacarpal Artery Flap with a Cutaneous Bridge Segment.

Background: The aim of this study is to compare outcomes of reconstruction of palmar versus dorsal defects of the thumb using the first dorsal metacarpal artery (FDMA) flap with a cutaneous bridge segment. Methods: All FDMA flaps done at our centre for reconstruction of traumatic thumb defects in the period from November 2017 to May 2019 were included in this study. Data with regard to the patient, the injury and the flap were recorded. The outcome measures recorded include flap survival, complications, duration of follow-up, static two-point discrimination (2-PD), cortical reorientation, paresthesia at the flap and donor site, pain at the flap and donor site, Kapandji score and aesthetic outcome. Results: The study included 11 patients with an average age of 35 years. All patients were men, and the injury involved the dominant thumb in seven patients. There were five dorsal defects and six palmar defects, and the average defect size was 7.22 sq cm. All flaps survived and there were no complications. The mean follow-up period was 15.2 months. The mean static 2-PD was 9.35 mm, cortical reorientation was complete in six patients, paresthesia score at the flap was 0.27 and at the donor site was 0.36. The visual analogue scale (VAS) pain for the flap was 1.09 and for the donor site was 1.27. The average Kapandji score was 8.64 and patients rated the aesthetic outcome of the flap at 8 and of the donor site at 7.36. There were no differences in outcomes between palmar and dorsal defects except for the aesthetic outcome of the flap that was rated better for dorsal defects. Conclusion: The FDMA flap designed with a cutaneous bridge segment provided reliable, single-stage reconstruction of dorsal and palmar thumb defects with good outcomes. Patients rated the aesthetic outcome of flaps used for dorsal reconstruction higher. Level of evidence: Level IV (Therapeutic).

Treatment of Nonreplantable Total Thumb Amputation at the CMC Level Using Index Finger Pollicization.

BACKGROUND: Pollicization of the index finger is a rarely performed reconstructive option for patients with total thumb amputations with nonsalvageable carpometacarpal (CMC) joint and thenar muscles. Successful pollicization can provide basic grasp and pinch to help patients carry out activities of daily living. We present a retrospective review of 4 patients who underwent index finger pollicization for traumatic total thumb amputations. METHODS: A retrospective review of 4 cases of pollicization using an injured index finger for traumatic thumb amputation was performed. Patients available for follow-up were contacted for functional assessment. Outcomes including range of motion (ROM), grip strength, key pinch, 2-point discrimination, and Disabilities of the Arm, Shoulder, and Hand score were obtained. Functional thenar muscle and the CMC joint were absent in all cases. Injury mechanism was firework in 2 patients and crush in 2 patients. RESULTS: The time from injury to pollicization ranged from 8 days to 17 months. Follow-up time ranged from 10 weeks to 3 years. Three patients regularly used the pollicized thumb in activities of daily living such as writing. Tip pinch and lateral pinch along with grip strength were weak in all cases; the best recorded pinch strength was 24% and grip strength was 25% compared with the contralateral hand. The ROM of the pollicized thumb was limited. CONCLUSIONS: Index finger pollicization following total thumb amputation can be a viable last-resort option for patients. The pollicized digit acts as a sensate post and avoids further morbidity from the traumatized extremity.