Immediate Distal Digit Reconstruction with Short Vascular Pedicled Partial Toe Transfer

We studied the results of the immediate microsurgical reconstruction of the distal digit injury with short vascular pedicled partial toe transfer. Thirteen patients with amputation or crush injury of the distal digit who underwent partial toe transfer at the authors' institute over 8-year period were reviewed. Delay between initial injury and reconstruction ranged from 1 to 9 days. All flaps were harvested on a short vascular pedicle, with anastomoses performed at a proximal interphalangeal joint level on the fingers and metacarpophalangeal joint level on the thumbs. Good to excellent cosmetic and functional results were obtained in all cases, with nearly normal-looking fingertip. The mean static two point discrimination was 10 mm. Immediate reconstruction with short vascular pedicled partial toe transfer is an excellent option for the reconstruction of the compostie defect of the distal digit.

Microsurgical Reconstruction of the Thumb

Compared with non-microsurgical reconstruction of the thumb, microsurgical reconstruction can provide more desirable postoperative results regarding to the function as well as appearance. Toe transfer in one of its forms offers many of the best ways to reconstruct defects of the thumb. For reconstruction of the pulp, nail, and the first web space, microsurgical transfer of required tissues provides excellent sensory restoration leaving little morbidity at the foot. For composite defect of the partial thumb amputations, wrap-around procedure and trimmed great toe transfer is one of the best options in cosmesis. Trimmed great toe transfer technique is to circumvent the lack of motion of the wrap-around flap. In cases of loss of the entire thumb, preliminary procedure is inevitable to avoid foot morbidity. After distant groin flap and autogenous bone graft, secondary toe-to-hand transfer is possible with great toe or second toe. Regarding to operation timing, preoperative planning is very important to induce rapport formation between patient and doctor. In case of malignant tumor resection, immediate reconstruction is much better than delayed reconstruction. Transfer of all parts of the great toe imparts some morbidity to the foot, but the effect when evaluated with gait studies is generally minimal. Certainly, the tradeoff of a thumb for the loss of the great toe is usually well-accepted by the patient. The primary disadvantage of these techniques is their inherent complexity and, although they offer superb reconstructive options in patients with loss of all or part of the thumb, their application should probably be limited to those practitioners with experience.

Cirugía reconstructiva de la mano / Hand reconstruction surgery

La cirugía reconstructiva de la mano y el desarrollo de ésta, está ligada al de la microcirugía. Requiere del dominio de varias disciplinas y, por parte del equipo tratante, establecer una estrategia de tratamiento desde el principio. Ideal es realizar toda la reconstrucción en un tiempo para iniciar una movilización precoz. El debridamiento inicial se continúa con la reparación de todos los tejidos de la mano. La cobertura constituye otro paso importante y lo ideal es realizarla en la atención de urgencia. La mano debe iniciar su rehabilitación en forma inmediata ya que lo contrario llevará a la instalación de la rigidez. Cuando no ha sido posible dejar una pinza básica de la mano, la reconstrucción de ésta pasa por el uso de técnicas de transferencias de ortejos a mano. La transferencia del hallux y de otros ortejos hoy son ampliamente usados y con excelentes resultados funcionales.

Reconstructive surgery of the hand and its development, is linked to microsurgery. Requires the mastery of several disciplines, and by the medical treating team, establish a treatment strategy from the beginning. Ideal is to do all the reconstruction at a time to begin early mobilization. The initial debridement is continued with the repair of all tissues of the hand. The coverage is another important and ideally do it in emergency care. The rehabilitation of the hand should start immediately and that otherwise lead to the installation of rigidity. If it is not possible to leave a basic gripper hand, reconstruction of this happens by using transfer techniques from toes to hand. The transfer of the hallux and other toesare widely used today with excellent functional results.

Ulna Nerve Compression Caused by a Tortuous Ulnar Artery

PURPOSE: This case report presents ulnar nerve compression which associated with variant distribution of ulnar artery at the proximal site of the wrist. MATERIALS AND METHODS: Based on the patient's symptoms, we could assume a neuropathy resulting from the compression of the ulnar nerve. The magnetic resonance imaging (MRI) was used to evaluate the anatomical abnormality of the ulnar artery at the site of compression, and the elecromyogram (EMG) and Nerve conduction velocity (NCV) were also performed to confirm the overall abnormality of the ulnar nerve. RESULTS: The tortuous ulnar artery of the lesion which was in the same course as that of ulnar nerve surrounded by sheath seemed to be compressed. Such finding was resolved 5 minutes after taking off tourniquet during adhesiolysis. Along with the improvement in the symptoms of paresthesia and the numbness of the patient a day after the surgery, the atrophy of the muscle and the weakness of the affected lesion were also slightly improved 6 months after the adhesiolysis. The decrease in abnormal spontaneous activity of the ulnar nerve was observed in both EMG and NCV, performed after the 6 month of the surgery. CONCLUSION: Among the patients manifesting significant symptoms of neuropathy arising from ulnar nerve compression, the tortuous ulnar artery as the source of entrapment of ulnar nerve was observed. Six months after the adhesiolysis of the sheath, the overall improvement of clinical symptoms was remarkable.

Second Toe Transfer for the Thumb Reconstruction

PURPOSE: Thumb is the most important part of the hand. That requires reconstruction as a top priority. The operative methods for thumb reconstruction have been developed variously to the microsurgical technique. For better functional and cosmetic effects of the thumb, many studies and reports on toe transfer for thumb reconstruction have been conducted. Great toe transfer for thumb reconstruction was first reported by Cobbett in 1969. Since then, the second toe transfer also has been reported by Dongyue in 1979. Author report about advantages and disadvantages of the second toe transfer for thumb reconstruction. MATERIALS AND METHODS: The second toe transfer had been conducted transfer for nine patients from March 1998 to February 2007. The patient's age ranged from 18 to 52, averaging 30 years old. The levels of defect were classified as two proximal portion of proximal phalanx,five metacarpo-phalangeal joints, and two distal portion of metacarpal bone. The causes of thumb defect were classified as six trauma, two electrical burn, and one malignant tumor cases. The results were evaluated with sensation and strength the reconstructed thumb, cometic effect of recipient site, aesthetic effects at donor sites, and gait problem, at mean 32 months after the operation. RESULTS: After the second toe transfer, the reconstructed thumb's sense was measured as average 8.2 mm at 2 point discrimination test and it's pinching power measured average 81.7% compared to normal thumbs. The degree of cosmetic satisfaction of both donor & recipient sites appeared at 3.4 and 4.7, respectively. CONCLUSIONS: When choosing an operative method for the thumb reconstruction, we have to consider functional and cosmetic effect as well as the socio-cultural background. If we apply the second toe transfer according to the amputation level of the thumb, it would be a good satisfying operative method.

Does Hallux Valgus Occur after Second Toe Transfer?

Second toe transfer is widely used to reconstruct digital defects or deformities. But it could cause any potentials for occurrence of hallux valgus. So the authors has evaluated the occurrence of hallux valgus after second toe transfer. The authors retrospectively analysed the results of 20 cases of second toe transfer which were performed from July 1997 to June 2001 in Pusan National University Hospital. To evaluate the occurrence of hallux valgus, we compared preoperative hallux valgus angles and first-second intermetatarsal angles with those of postoperative results. Also the clinical evaluation of patients' subjective assessment and foot pressure meter was used to compare the donor foot with normal foot after operation. Although hallux valgus angle and intermetatarsal angle were increased to a few degrees after second toe harvesting, but there were no statistical significances(p>.05). According to the patients' subjective assessment, none of the patients showed clinically significant valgus deformities. By a foot pressure meter, no specific different results were detected between donor foot and normal foot. In conclusion, the second toe can be harvested safely without fear of causing hallux valgus in the donor foot if the metatarsal bone is not involved in harvesting.

An anatomical study and clinical application of free transfer of foot tissues pedicled with plantar metatarsal artery / 中华创伤骨科杂志

Objective To explore a new method of functional reconstruction of hand digits and joints with free transfer of foot tissues so as to increase the success rate of the operation.Methods After micro-anatomic study of the plantar and dorsal metatarsal arteries,retrograde and free grafts of foot tissues pedicled with plantar metatarsal arteries were designed and applied in transplantation to treat 76 cases of hand digital or joint defects.The surgeries included 58 cases of transfer of the second toe,four cases of transfer of composite tissues of the second toe, eight cases of transfer of proximal interphalangeal joint,and six cases of nail flap transfer.Results The mi- cro-anatomic study found that the first plantar metatarsal artery was anatomically constant and the diameter of its branch to the second toe was larger than that of the first dorsal metatarsal artery.Flaps survived in 75 of the 76 patients(98.7%),with fine appearance and significantly improved function.One patient who had received free transfer of the second toe to reconstruct the thumb function had to undergo a second repair with infraclavicula skin tube because of refractory arteriospasm of anastomosed vessels.Conclusion Transfer with free retrograde grafts of foot tissues pedicled with plantar metatarsal artery to reconstruct hand functions can effectively improve the success rate of the operation,because it is free of the shortcomings of great anatomic variation of blood vessels and time-consuming and complex procedures in conventional transfer.

Cosmetic Reconstruction of Distal Finger with Second Toe-to-Hand Transfer

A series of 17 distal finger reconstructions was successfully performed with second toe-to-finger transfer for the aesthetic purpose. The static 2-point discrimination averaged 9 mm. Total active range of motion was 205 degrees. The mean extension deficit of transferred toe was 10 degrees. Key-pinch and grip power averaged 65% and 90% of the normal opposite site respectively. The subjective satisfaction scores of aesthetic appearance and function on the new reconstructed distal finger by patients' self-assessment were 82 and 78 in average, respectively, over a total score of 100. And, those of foot averaged 88 in function and 77 in aesthetic appearance. For aesthetic refinement in distal finger reconstruction with second toe-to-hand transfer, skeletonization of the neurovascular bundle of the harvested toe as well as intraoperative expansion of the subcutaneous tunneling between skin incisions can avoid unsightly scars on the reconstructed fingers. Defatting of the skin flaps of the amputated fingertip and zigzag incision on the toe flap lead to smooth junction between the amputated digit and the transferred toe. Arterial microanastomosis was done at the interdigital web space to avoid small caliber of the pedicle and cold intolerance. Cosmetic reconstruction of the distal finger with second toe-to-hand transfer leads to high satisfaction of the patients both aesthetically and functionally. This is another new field of cosmetic surgery for the distal finger defects.