From Autotransplantation to Allotransplantation: A Perspective on the Future of Reconstructive Microsurgery.

It has been half a century since Susumu Tamai reported on the first thumb replantation. The evolution of reconstructive microsurgery has continually added new applications of the operating microscope for reconstructive surgery and has had profound impact on countless patients. From the time of Harold Gillies until today, the reconstructive ladder has evolved to a reconstructive elevator with the "penthouse" floor being represented by vascularized composite allotransplantation.

Clinical Presentation, Surgical Treatment, and Outcome in Radial Polydactyly.

Radial polydactyly or 'thumb duplication' is the most common congenital upper limb anomaly ('CULA') affecting the thumb. The clinical presentation is highly diverse, ranging from an extra thumb floating on a skin bridge to complicated thumb triplications with triphalangeal, deviating, and hypoplastic components. Radial polydactyly can be classified into one of 7 osseous presentations using the Wassel classification, with type IV (45%), type II (20%), and type VII (15%) occurring most frequently. When faced with a radial polydactyly case, hand surgeons specialised in congenital anomalies must weigh the preoperative functional potential and degree of hypoplasia of both thumbs in order to decide whether to resect one thumb and reconstruct the other ('resection and reconstruction'), excise a central part of both thumbs and unite the lateral tissues into one thumb ('the Bilhaut procedure'), transfer the better-developed distal tissues of one thumb onto the better-developed proximal tissues of the other ('on-top plasty'), or discard both severely hypoplastic thumbs and pollicise the index finger. Mere excision of the hypoplastic thumb is rarely indicated since it often requires subsequent revision surgery. Even after being treated by experienced surgeons, about 15% of patients with polydactyly will need additional procedures to correct residual and/or new problems such as deviation from the longitudinal axis and joint instability. Nevertheless, radial polydactyly patients usually achieve unimpaired everyday hand function postoperatively.

Pulgarización en Síndrome de Nager. Caso clínico / Pollicization in Nager Syndrome. A case report

El tratamiento de las hipoplasias del pulgar, independientemente del síndrome clínico en el que estén incluidas, se basa en su severidad. La pulgarización, migración quirúrgica del índice hacia la posición del pulgar para sustituir su función, se reserva para los casos más severos. Presentamos el caso de un varón de 4 años de edad con Síndrome de Nager. Entre las características clínicas más significativas del caso destacamos: paladar hendido, microtia bilateral, fisura palpebral antimongoloide, hipoplasia malar, hipoplasia mandibular, coloboma del párpado inferior, así como hipoplasia severa bilateral de pulgares y ausencia parcial de tibia. Realizamos procedimiento de pulgarización en mano derecha sin complicaciones, con evolución satisfactoria. Tras 18 meses de seguimiento, el paciente presenta prensión esférica y cilíndrica adecuada, prensión lateral, así como oposición al quinto dedo (AU)

Treatment paradigm for a child with thumb deficiency or hypoplasia is based on severity, apart from other clinical features. Pollicization or surgical substitution of the thumb, most commonly using the index finger, is reserved for the most severe cases. We present the case of a 4-year-old male with Nager Syndrome. Among the most notable clinical characteristics we found: cleft palate, bilateral microtia, downslanting palpebral fissure, malar hypoplasia, mandibular hypoplasia, lower eyelid coloboma, partial tibial agenesis as well as bilateral hypoplastic/absent thumbs. Pollicization was performed for the right hand without complications. After 18 months follow-up, adequate cilyndrical and spherical grasp was achieved, as well as lateral prehension and opposition to fifth finger (AU)

Reconstrução do Polegar Metacárpico com Transplante do Segundo Artelho: 12 Anos de Evolução

Paciente masculino, 16 anos, sofreu lesão na mão direita com serra circular em acidente de trabalho. Foram propostas a reconstrução do polegar com transplante do segundo artelho e a osteossíntese das sequelas das fraturas das falanges do III e IV dedos

Reimplante de pulgar: caso clínico / Replantation of thumb: clinical case

We report successful case of a complete thumb amputation. The conditions of the wound surfaces were pretty sharp and contamination was slight. The replantation surgery was done by the same team. After a two months follow up the restoration of thumb function was satisfactory

Pulgarización de dedo índice en ausencia congénita e hipoplasia del pulgar / Pollicization of the index-finger for patients who have congenital absence or hypoplasia of the thumb

Se evaluaron los resultados de 17 pulgarizaciones del dedo índice en 15 pacientes con ausencia congénita o hipoplasia del pulgar, en un periodo conprendido de septiembre de 1982 a diciembre de 1992 en el Hospital Shriners para niños lisiados, Unidad México. La edad promedio al momento de la pulgarización fue de nueve años cuatro meses y el seguimiento fue en promedio de cuatro años y 10 meses. En 11 manos se obtuvo una pinza gruesa y fina fuerte (65 por ciento) y 13 manos realizaron oponencia con la punta de los dedos (76 por ciento). Todos los dedos pulgarizados son estables. Tanto los pacientes como los familiares refieren una mejoría cosmética y funcional significativa. La pulgarización del índice en la ausencia congénita e hipoplasia del pulgar, permite que el índice pulgarizado tenga movilidad activa propia sin depender de transferencias musculares

Reconstruction of radial half hand by using combined transplantation of pedicled phalanx, free toe, and island flap.

Combined transplantation of 1) a residual proximal phalanx flap of the thumb with a fascial pedicle, 2) a reversed island flap based on the posterior interosseous artery, and 3) a free second toe was successfully used to reconstruct the radial half of the hand in a patient who had experienced loss of the second metacarpal bone and index finger, a defect to the shaft of the third metacarpal bone, and dry gangrene of the thumb, two-thirds of the radial dorsal skin and the first web space of the left hand. The reconstructive result was satisfactory and took advantage of each tissue flap. The operation was relatively simple and was completed in one stage. We believe the procedure provided good recovery of function and appearance at an appropriate cost.

[The strategy of the finger bank]. / Stratégie du doigt banque.

The authors present 40 cases of multidigital amputations with a "bank-finger" reconstruction. They use of flaps, tendons, nerves grafts .... from the injured finger. Moreover, they propose a guide in the use of heterotopic implantations, in emergency and in secondary. The indications of the digital translocation is discussed about the priority finger and the localisation of the others fingers to be reimplanted. They make mention of the rare possibility of temporary ectopic implantation.

Cross thumb transfer.

Thumb reconstruction following amputation was accomplished by microvascular transfer of the thumb from the contralateral paralyzed hand in two cases. The appearance and function of the transferred thumbs were excellent and no problem was seen in the donor hand.

[Functional improvement in the treatment of large soft tissue defects of the thumb by a free tissue transplant]. / Funktionelle Verbesserungen in der Versorgung grosser Weichteildefekte am Daumen durch eine freie Gewebeübertragung.

The advantages of free transplantation used to cover defects of the thumb are demonstrated with the aid of a clinical example. A 27 years old patient had lost large parts of the covering soft tissue as well as the nerves and vessels on the flexor side of the distal phalanx of his left thumb. After a single wound toilet the thumb could hardly be used because of the reduced mechanical resistance to stress, the missing sensibility and a severely disturbed circulation. This kind of large soft tissue defect at a functionally important location can now be covered with a free composite tissue transplantation. We took a neurovascular flap out of this patient's forefoot and anastomosed it with the vessels and nerves of the proximal phalanx of the thumb. After an uncomplicated healing the covering soft tissue could be mechanically stressed and was well supplied with blood. Three month later a beginning sensibility can be proved. After 2 years the fully rehabilitated patient shows a good functional result with a two-point discrimination of 10 millimeters.