Proximal toe wrap-around: a coverage technique for circumferential skin defects of the fingers.

Circumferential skin defects of the fingers are a technical challenge. Although rare, their management should respect tissue organization and functional abilities. We report two cases of circumferential skin defect. Management used individually tailored "wrap-around" flaps taken from the hallux. The sample concerned the proximal cutaneous sheath of the first toe and the neurovascular pedicle of the first inter-metatarsal space. Nail and toe pad were spared. Both cases had complex circumferential skin defect of the finger, involving the neuro-vascular pedicle. Postoperative results were favorable, without functional limitation. The wrap-around technique provided skin coverage and also neurovascular pedicle reconstruction. Donor site damage was limited, with no functional consequences. This technique is a valuable option for management of circumferential skin defect of the finger.

A functional "metacarpal-hand" after a firework injury obtained without any flap or toe-transfer.

A 37-year old male patient with a right-hand firework injury. An extreme hand reconstruction was performed. The second and third rays were sacrificed enlarging the first space. The diaphysis of the second metacarpal bone became a tubular graft to reconstruct the fourth metacarpal. The thumb consisted only in the first metacarpal bone. The result was satisfactory, according to the wishes and needs of the patient, a three-finger hand with an opposable thumb, obtained in only one surgical treatment and without using free flaps. The concept of an "acceptable hand" is related to the surgeon's and patient's opinions.

A new method for second toe flap revascularization in plantar dominant artery pattern - dorsal metatarsal artery interpositional graf.

BACKGROUND: Toe transfer to hand is a viable option for patients, which can provide functionally useful digits. Harvesting of the second toe is still accepted as a demanding surgical procedure. The major questions before this transfer are the location and the dominance of the arterial anatomy of the second toe. The authors present the incidence of patients with a dominant plantar artery system and a description of a versatile technique that can be used for toe transfers in these patients. METHODS: The study was designed retrospectively. Toe to hand transfers performed between 2010 and 2018 were reviewed. The patients with a dominant plantar arterial system were included in this study. The dorsalis pedis arterial graft technique described by the authors was used in all cases with a dominant plantar system. All of transfers were done by the senior author. All cases followed up at least one year post-operatively. The survival of the transferred finger was examined in the follow-ups. RESULTS: Eleven toe to hand transplantation cases in nine traumatic patients were included in this series. The reason for the operation was trauma in all patients. Second toe transfer was performed in all of the cases. Plantar dominant arterial system was seen in 3 of the 9 patients. Dorsal arterial system was dominant in the remaining six patients. Dorsalis pedis arterial graft technique was used in these four cases. All of the toes survived, and reexploration was needed in 2 cases because of venous insufficiency. Mean follow-up time was 16.4 months. DISCUSSION: This is the first study to recommend the use of dorsalis pedis as an arterial graft instead of vein grafts. This surgical method described will make these rarely performed transfers easier and affect the success rates positively.

Distal finger reconstruction technique combining a distally-based finger flap and a partial toe flap.

BACKGROUND: Although aesthetic reconstruction of an amputated distal finger can be achieved through partial toe transfer, this approach often damages the weight-bearing region of the toe from which the flap is harvested. The purpose of this report is to introduce the minimum invasive surgery technique to reconstruct the distal finger aesthetically without damaging the weight-bearing region of the toe. PATIENTS AND METHODS: Thirty-one amputated fingertips in 30 patients aged 18 to 68 years were treated using this operative technique. Operations were performed between January 2010 and December 2020. All patients were missing the distal finger beyond the PIP joint, and the amputation stump had been covered with healthy skin. A distally based finger flap was elevated at the recipient site, and a slender partial toe flap, including the nail, was harvested from the great toe. These flaps were combined to form the distal finger. In all cases, the weight-bearing region of the toe remained intact. The donor site wound was first closed with artificial dermis, and skin grafting was performed 3 weeks after the surgery. A few patients did not require skin grafting because their wounds epithelized spontaneously. RESULTS: In most patients, the transplanted flap remained healthy and the distal finger was aesthetically restored. Two patients aged over 60 years who were smokers developed necrosis of the transplanted partial toe flap. In all patients, the weight-bearing region of the great toe was intact, and they had no trouble walking during the three-year follow-up period after surgery. CONCLUSION: Our technique, which combines elevation of a distally-based finger flap and transplantation of a partial toe flap, was able to minimize the skin defect area in the great toe. This new distal finger reconstruction technique is minimally invasive and can be used to prevent secondary donor site issues.

Versatility of the Posterior Interosseous Artery Flap: Emphasis on Powering Up the Toe Transfer.

BACKGROUND: Reverse-flow posterior interosseous artery (rPIA) flap is an excellent tool for restoration of defects in the hand and upper extremity, sparing the main arteries to the hand. Its reliability has been well established. MATERIALS AND METHODS: Fifty-one cases of rPIA flap involving 49 patients were retrospectively reviewed. The inclusion criteria were age, sex, etiology, size and location of the defect, flap size, number of perforators included, pedicle length, flap inset, donor site coverage, complications, and ancillary procedures. RESULTS: This study included 44 men and 5 women, ranging in age between 10 and 73 years. The subjects had soft tissue defects of the hand and upper extremity mainly due to traumatic injuries, including scar contractures of the first web space in 18 cases, thumb amputations in 6 cases, and congenital defects in 1 case. Among the 51 rPIA flap elevations, 3 cases involved flap failure due to the absence of proper pedicle. A fasciocutaneous pattern was observed in 45 cases and a myocutaneous pattern in 3 cases. In 5 cases of unplantable thumb amputations, the rPIA flap was performed for arterial inflow to the secondary toe-to-thumb transfer. Venous congestion of varying degrees was noted in 7 cases involving partial necrosis in 2 cases. During the mean 17 months of follow-up, patients were generally satisfied with the final outcomes. CONCLUSION: The rPIA flap can be used not only for soft tissue coverage of the hand and upper extremity but also as a recipient arterial pedicle for a secondary toe-to thumb transfer.

Repair of finger pulp defects using a free second toe pulp flap anastomosed with the palmar vein.

PURPOSE: To evaluate the clinical utility of surgical reconstruction of finger pulp defects using a plantar flap derived from the toes, with vascular anastomosis of the toe-finger artery and the plantar-palmar vein of the finger. METHODS: Between April 2018 and November 2020, 29 patients with finger pulp defects underwent treatment via the transplantation of pulp tissue from the second toe, with the plantar vein of the toe and the palmar vein of the finger being anastomosed during this procedure. In addition, an anastomosis of the toe and finger artery and nerve was conducted, with a flap size of 1.0 cm * 0.8 cm-2.3 cm * 4.0 cm being used for such repair. Donor tissue sites were closed without introducing deformities or other complications. RESULTS: In all patients in the present study, flap tissues survived and did not exhibit evidence of vascular crisis over a mean 16.8-month follow-up period (range 8-24 months). After successful skin flap grafting, they exhibited good elasticity and a soft texture. At three months post-surgery, some patients reported partial recovery of touch sensation in the transplanted tissue, while pain recovery was evident in some patients at 4-6 months post-surgery. No deformities or other complications were observed at the donor site, and the ability of patients to walk normally was not impaired. CONCLUSION: The anastomosis of toe plantar flaps with the palmar vein can facilitate the repair of finger pulp injuries without the need to dissect the dorsal vein of the toe, allowing for the suturing of donor tissue sites without causing any deformities or other complications. This surgical approach can easily be conducted with satisfactory clinical outcomes.

A new surgical strategy for reconstruction of claw nail deformity.

Claw nail deformity is common in patients with fingertip injury. The optimal reconstruction remains unclear. We devised a unique strategy for reconstruction of claw nail deformity. We divided the approach into three parts: soft tissue reconstruction, bone graft and nail bed graft. In the soft-tissue reconstruction, a reverse digital arterial finger flap for the finger or an extended palmar flap advancement with V-Y plasty for the thumb was selected. A part of the distal phalanx of the second toe including periosteum was harvested as a bone graft. A nail bed graft from the big toe was performed. We reconstructed in 11 cases of claw nail deformity using our strategy. All cases achieved significant improvement with no recurrence of the claw nail deformity. Moreover, there was no donor site morbidity.

Use of single-staged transmetatarsal trimmed great toe transfer for reconstruction of a thumb amputation at the carpometacarpal joint.

BACKGROUND: Reconstruction for proximal thumb amputation at the carpometacarpal (CMC) joint level is extremely challenging. All thenar muscles are lost and other fingers might be lost or injured. Transmetatarsal trimmed great toe (TGT) transfer may be an option in such cases. METHODS: Between 2012 and 2018, 11 patients who had amputation of the thumb at the CMC joint level were reconstructed by transmetatarsal TGT transfer in a single stage. There were seven cases in which the right hand was affected and four cases in which the left hand was affected. Three cases involved a contracture scar at the thumb stump and required web space reconstruction. Average follow-up was 33.9 months (range: 12-76 months) RESULTS: All toe transfers survived. The average of static two-point discrimination (S2PD) was 14.6 mm; the average scores of the Quick Disabilities of the Arm, Shoulder, and Hand (quickDASH) questionnaire and the Michigan Hand Outcomes Questionnaire (MHQ) were 18.6 and 73.8, respectively. Two cases did not achieve opposition due to mispositioning of the neothumb. In nine cases achieving opposition, the Kapandji score ranged from 4 to 9, pinch ranged from 3 to 11 lbs, and grip ranged from 15 to 86 lbs. In the donor foot, three patients had neuroma and two had a new callus on the palmar side of the second and third metatarsal heads. The average foot and ankle disability index score was 91.6. CONCLUSION: Single-staged transmetatarsal TGT transfer is safe and useful for thumb reconstruction at the CMC joint level. This reconstructive method is suitable for manual workers, especially in the developing countries.

Cosmetic and functional results of a newly reconstructed thumb by combining the phalanx of second toe and the great toenail flap transplantation.

BACKGROUND: Microsurgical toe-to-hand transfer is a gold standard when it comes to repairing a thumb defect. Great toenail flap, thumbnail valva flap, free great toe, and second toe transplantation are the common methods in thumb reconstruction. Second toe transplantation achieves good function, but poor esthetics. Great toe transplantation achieves better esthetics, but hindered walking, due to the foot's loss of the great toe and moreover suboptimal thumb function. It is difficult to maintain both functional and esthetic satisfaction in thumb reconstruction. METHODS: We experimented with three different methods of toe to hand transfer. From October 2009 to July 2019, 30 patients with traumatic thumb defects received one of 3 different kinds of thumb reconstruction in our clinic according to their level of amputation. Divided evenly into three groups of ten, group one received a great toe transplantation, group two received a second toe transplantation, and group three received a combined great toenail flap and second toe phalanx transplantation. Each of the patients' thumbs had different levels of amputation at the metatarsophalangeal joint (MPJ) or distal interphalangeal joint (DIPJ). RESULTS: One patient suffered from a partial flap necrosis and received a groin flap to cover the defect. No other thumbs had any complications. The functional and esthetic results of both the donor and the recipient sites were satisfactory. Results show that, for patients with traumatic thumb defects, the combined transfer of flap and second toe phalanx was the best option. CONCLUSIONS: Compared to the great toe or second toe transfer, combined free transfer of the great toenail flap and second toe phalanx achieved a substantially better functional and esthetic result in the thumb reconstruction.

Importance of preserving redundant pulp skin in thumb terminalization to allow subsequent reconstruction with on-top toe transfer: A clinical case (with video).

Traumatic thumb amputations can seriously jeopardise hand function. Several alternatives for reconstructing an opposable thumb have been described, including distraction osteogenesis, index finger pollicisation and free toe transfer. We present in this article the case of a young male patient that sustained a circular saw injury to his non-dominant thumb which resulted in loss of his distal phalanx. Preserving the sensate pulp allowed later reconstruction with an on-top free second toe transfer achieving a satisfactory outcome.

The Second Toe-to-Hand Transfer for Full-length Thumb Reconstruction in Congenital Thumb's Grade IIIb to V Hypoplasia: MTPJ Arthrodesis Instead of Tendon Rebalansing.

Congenital thumb hypoplasia is a rare deformity of the upper extremity. The classification of thumb hypoplasia was created by Blauth in 1967 (types I to V). The base of the first metacarpal bone is absent for hypoplasia types IIIb to V, therefore, toe-to-hand transplantation is not recommended. A stable first carpometacarpal joint has been considered a mandatory factor for a successful toe-to-hand transplantation. The aim of this study is to describe a new technique for thumb reconstruction with the second toe transfer and metatarsophalangeal joint (MTPJ) arthrodesis, which can provide a five-digit hand and restore thumb functionality for thumb hypoplasia IIIb to V. We performed second toe-to-hand transplantation with MTPJ arthrodesis for 3 pediatric patients (mean age, 69 mo) with congenital thumb hypoplasia IIIb (n=2), grade V (n=1). Long-term follow-up evaluated the functions and esthetics of the hands for grade IIIb patients (n=2). We believe the second toe transfer with MTPJ arthrodesis transplantation is a promising method for reconstructing a full-length congenital or traumatic thumb absence for the pediatric population.

Clinical effect of thumb finger reconstruction using dorsal foot flap transplant for treating thumb defects.

It was found that conventional toe graft alone could not meet the patients' needs for wound repair, so we hypothesized that it would be more effective to treat thumb and finger defect by toe graft with dorsalis foot flap. This prospective study was conducted in 104 thumb defect patients to investigate the clinical effect of thumb reconstruction using toe graft with dorsal foot flap for the treatment of thumb defects. These patients were randomly divided into the dorsal foot group and the control group by randomized double-blind method, with 52 patients in each group. The second toe was used for thumb reconstruction transplant in both the groups. After thumb reconstruction, the abdominal pedicled flap was used to repair the surgical wound in the control group whereas the dorsal foot flap was used to repair the surgical wound in the dorsal foot group. Three months after surgery, the efficacy of surgical treatment, evaluation of two-point discrimination, postoperative complications, function of reconstructed thumb, operation time, and hospitalization time were recorded and compared between the two groups. MHOQ questionnaire was used to evaluate and compare the patients' satisfaction with finger reconstruction in both the groups. The surgical therapeutic effect, the function of the reconstructed thumb, and satisfaction with finger reconstruction were significantly higher in the dorsal foot group compared to the control group (all p < 0.05). The postoperative two-point discrimination, postoperative complication rate, operation time, and hospitalization time of patients in the dorsal foot group were significantly lower compared to the control group (all p < 0.05). Thumb finger reconstruction using the second toe transplant with dorsal foot flap had a beneficial effect on thumb defect patients. It can effectively improve finger function and sensory recovery of patients while reducing complications.

Immediate vs. delayed toe-to-thumb transfer: Is the infection rate greater?

BACKGROUND: After loss of a thumb, the big toe is a possible donor site for reconstruction with wrap-around free flap and trimmed-toe transfer techniques. Early reconstructions seem to reduce the risk of post-operative infections, despite several studies that show different infection rates of the recipient site in immediate toe-to-hand transfer. The authors carried out a retrospective analysis of their experience in thumb reconstruction with big toe transfer and evaluated the results achieved with both immediate and delayed reconstructions in terms of infection occurrence. PATIENTS AND METHODS: From 2000 to 2017, patients who presented cut, crush and avulsion injuries in the thumb were selected and 33 toe-to-thumb transfers were performed. Patients were divided into two groups: in group A, patients underwent immediate reconstruction, while in group B delayed reconstructions were performed. The two groups received identical antimicrobial prophylaxis. Reliability of the immediate or delayed reconstruction was compared in terms of flap survival, requirement for a secondary intention healing and, in particular, rate of infection. RESULTS: 29 male and 4 female patients were treated. Toe-to-thumb transfers were performed in both groups: in group A, 8 wrap-around free flaps and 4 trimmed toe transfers; in group B, 11 wrap-around and 10 trimmed toe transfers. No flap loss occurred in either groups. No cases of infection were detected in the transferred toes. CONCLUSION: For toe-to-thumb transfer, there are published reports of a wide range of infection rates of the recipient sites. The authors compared their results in terms of infection rate between immediate reconstruction, group A, and delayed reconstruction, group B. Immediate toe-to-thumb transfer showed equal success rates to delayed transfer. No statistically significant difference in risk of infection between the two groups was found. Results showed that the immediate reconstruction was as safe and reliable as the delayed one.

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.

[Secondary digit reconstruction of mutilated hand]. / La chirurgie secondaire après amputation digitale traumatique.

Traumatic digit amputation generates functional, aesthetic and psychological disabilities. Such post-traumatic consequences call for a rigorous therapeutic approach, aiming at an early secondary surgical procedure - which is ideally to be performed before the patients psychologically recover from their initial trauma. The therapeutic principle consists in improving the global function of the hand, basically aiming at re-creating a quality pollici-digital pinch, ideally thin, stable, sensitive, strong, mobile enough, but also, when possible, at improving the aesthetic aspect of the hand. The therapeutic arsenal includes not only surgical processes using local ressources in order to improve the allocation of the remaining digital capital such as phalangisation, elongating techniques, proximal amputation, digital translocation and redistribution but also remote processes - such as osteoplastic and toe-to-hand transfer techniques. The authors expose their approach and indications of secondary digit reconstruction procedures in mutilated hand. They conclude that a thorough knowledge and mastery of the vast available therapeutic arsenal, a fine and profound analysis of the benefits and downsides of each available surgical technique, a comprehensive acknowledgement of the patient's personal information such as age, gender, profession, dominant hand, status of the mutilated hand, physical and psychological health as well as patient's desire are all necessary in order to define the best therapeutic strategy for each particular case.

Methods for Congenital Thumb Hypoplasia Reconstruction. A Review of the Outcomes for Ten Years of Surgical Treatment.

BACKGROUND AND OBJECTIVES: Congenital thumb hypoplasia is a rare deformity of upper extremity. The incidence for thumb hypoplasia grade II-V is 1:10,000 newborns per year in Latvia. A technique for extensor indicis proprius (EIP) tendon transfer with subperiosteal fixation was developed and used for thumb hypoplasia grades II and IIIa. Pollicization or second-toe-to-hand transplantation with metatarsophalangeal (MTP) joint arthrodesis was used for the reconstruction of hypoplasia grade IIIb-V. The aim of this retrospective cohort study is to evaluate the outcomes for reconstruction techniques used in one surgical center during a ten-year period by one surgeon to evaluate functional and aesthetical outcomes for new techniques. MATERIALS AND METHODS: In total, 21 patients were operated on during 2007-2017, and 18 of these patients were involved in this study. Long-term follow-up was completed to evaluate the functions and aesthetics of the hands. RESULTS: disabilities of the arm, shoulder and hand (DASH) was 9.35 (8-10.7) for the second-toe-to-hand with MTP joint arthrodesis transplantation method for pollicization method 19.8 (6-26.7), and for the EIP tendon transposition, 14.54 (0.9-56.3). CONCLUSIONS: The postoperative functional parameters of congenital hand hypoplasia patients, regardless of the surgical method, are worse than the functional results of healthy patients. The use of the second-toe-to-hand with MTP joint arthrodesis transplantation method provides patients with congenital hand IIIb-V hypoplasia a stable and functional first finger formation. The functional results are comparable to the clinical results of the pollicization method while ensuring the creation of a five-digit hand.

Extreme Thumb Losses: Reconstructive Strategies.

BACKGROUND: Historically, complex amputations of the thumb have been managed in two stages and often require additional soft-tissue and tendon transfer for successful outcomes. This article provides several novel strategies to address these problems in a single stage using existing muscles, immediate free tissue transfer, and toe transfer. METHODS: From a personal experience of 482 toe transfers, 24 cases were performed to reconstruct extreme thumb losses. All thumbs were reconstructed in one stage. In only one case, the thumb was reconstructed with a second toe transfer; the remainder had a great toe (or a part of it) used for reconstruction. Suture, advancement, or tendon transfers were performed in all to restore intrinsic muscle function. In 19 cases, the web needed to be resurfaced with free (n = 18) or local (n = 1) flaps. RESULTS: All toes and flaps survived. Three patients required a secondary adductorplasty. Six of the seven patients with a metacarpal hand were able to perform tripod pinch. The rest had an average Kapandji opposition score of 7.5. Patients rated their functional and cosmetic result with a visual analogue scale score (ranging from 0 to 10) of 8.5 and 8.4, respectively. CONCLUSIONS: In proximal thumb amputations, the surgeon should pay attention not only to the obvious thumb loss but also to the first web and the thenar muscles. The author recommends abandoning the standard approach of a pedicled groin flap followed by a toe. Otherwise, the thenar muscles become useless, the first metacarpal contracts, and the need for tendon transfers skyrockets. Further studies are required to compare the outcomes of these results to those of more classic transfers. CLINICAL QUESTION/LEVEL OF EVIDECE: Therapeutic, IV.

Novel Technique for Toe-to-Hand Transplantation: The Fourth-toe as an Alternative Option for Toe-to-Hand Transplantation for Pediatric Patients.

The first toe-to-hand transplantation was done in 1898 by Nicoladoni. It was a staged procedure and the toe flap was based on a pedicle. With advancement of optical instruments and microsurgeons' skills in 1964 the first microvascular toe-to-hand transplantation on a rhesus monkey was done. The technique's development has not stopped, many authors have modified it to achieve better outcomes for both traumatic and congenital hand defects. The most commonly used toes for transplantation are first, second, and second to third toe block. Well described plantar and dorsal vascular systems for first web space vessels as well as possibility to perform successful perforator anastomosis allows us to improve toe-to-hand transplantation further. There is a paucity of studies on single fourth toe-to-hand transplantation. We performed fourth-toe transplantation for three pediatric patients (mean age, 73 mo) with congenital (n=2) and traumatic (n=1) hand defects. Common plantar digital arteries were used for blood supply to the transplanted toes. No vascular problems occurred, and all transplanted toes survived. Patients and parents are satisfied with functional and esthetic outcomes. Early podometry results show insignificant changes which should not harm the foot in the long-term. We believe the fourth-toe transplantation is a promising method to use to reconstruct congenital or traumatic absence of digits for pediatric population.