Nonvascularized Toe Joint Transfers to the Hand in Young Children: Technique Revisited.

BACKGROUND: Small joint reconstruction of the hand poses a significant challenge, especially in children where both functional motion and preservation of the epiphysis are desired. Auto-transplantation of whole joints is the only way to reconstruct a functional joint that maintains growth potential. Historically, nonvascularized toe-to-finger joint transfer has been criticized for high rates of avascular necrosis and joint dissolution, while vascularized transfers seemingly resulted in increased durability of the joint space and epiphysis. However, certain populations remain poor candidates for microvascular reconstruction, such as those with congenital deformities or sequelae from trauma or infection. In our case series, we demonstrate that a simplified nonvascularized surgical technique and careful patient selection can produce stable, functional joints. METHODS: Nonvascularized toe-to-finger joint transfer was performed in 3 children between the ages of 4 and 6. Reconstructed joints included 2 proximal interphalangeal (PIP) joints and 1 metacarpophalangeal (MCP) joint. Donor grafts consisted of second toe PIP joints harvested en bloc to include the epiphysis of the middle phalanx, collateral ligaments, volar plate, and a diamond-shaped island of extensor tendon with its central slip attachment. RESULTS: Follow-up ranged from 7 to 29 months. Each patient demonstrated functional improvements in joint motion and stability. Postoperative radiographs confirmed adequate joint alignment and persistence of the joint spaces. Epiphyseal closure was observed in 1 patient as early as 25 months postoperatively. CONCLUSIONS: Nonvascularized joint transfer should remain a practical consideration for small joint reconstruction of the hand in certain pediatric patients.

Vascularized toe joint transfers to the hand for PIP or MCP reconstruction.

Vascularized toe joint transfers are used for proximal interphalangeal (PIP) or metacarpophalangeal reconstruction of the fingers in children or young adults, as an alternative to joint arthroplasty. In children, this reconstruction aims to restore range of motion (ROM) and the growing capacities. The typical donor sites are the PIP or metatarsophalangeal joints of the second toe. These transfers are performed with short vascular pedicles in order to simplify the surgical technique and reduce the overall morbidity. Local flaps and joint fusion are used to reconstruct the donor toe. Indications for these transfers are mainly compound defects due to trauma or infection. While these reconstructions provide a long-lasting result, the ROM achieved is always smaller than the normal ROM of the recipient joint.

Microvascular Toe Joint for Proximal Interphalangeal Joint Replacement: Indications, Technique, and Outcomes.

Microvascular toe interphalangeal joint transfer can serve as a means of autogenous digit proximal interphalangeal joint (PIPJ) arthroplasty. Among surgical options for treating dysfunctional, absent, or destroyed PIPJs, free toe joint transfer is the most technically challenging and carries the greatest donor site cost to patients. Despite drawbacks, free toe joint transfer is a valuable tool with considerable advantages over conventional arthroplasty in the appropriate clinical setting. Particular advantages include lifelong durability, coronal plane stability, low infection risk, and growth potential in skeletally immature patients. This technique requires a balanced assessment of the risk-to-benefit ratio for each patient.

Proximalization of the Vascularized Toe Joint in Finger Proximal Interphalangeal Joint Reconstruction: A Technique to Derive Optimal Flexion From a Joint With Expected Limited Motion.

When used to reconstruct a finger proximal interphalangeal joint, a free toe interphalangeal joint, without modification, cannot meet the motion demands of the finger to allow palm touchdown. This limitation is the direct result of the toe interphalangeal joint having an intrinsic arc of motion that delivers less flexion than that of a normal functioning finger proximal interphalangeal joint. By modifying the inset of the transferred joint to an extra-anatomical more proximal position, this limitation can be overcome. With a mathematical justification highlighted by a clinical illustration, we demonstrate the feasibility and utility of this "proximalization" technique.

Customizing Extensor Reconstruction in Vascularized Toe Joint Transfers to Finger Proximal Interphalangeal Joints: A Strategic Approach for Correcting Extensor Lag.

BACKGROUND: Vascularized toe proximal interphalangeal joint transfer allows the restoration of damaged joints. However, extensor lag and poor arc of motion have been reported. The authors present their outcomes of treatment according to a novel reconstructive algorithm that addresses extensor lag and allows for consistent results postoperatively. METHODS: Vascularized toe joint transfers were performed in a consecutive series of 26 digits in 25 patients. The average age was 30.5 years, with 14 right and 12 left hands. Reconstructed digits included eight index, 10 middle, and eight ring fingers. Simultaneous extensor reconstructions were performed and eight were centralization of lateral bands, five were direct extensor digitorum longus-to-extensor digitorum communis repairs, and 13 were central slip reconstructions. RESULTS: The average length of follow-up was 16.7 months. The average extension lag was 17.9 degrees. The arc of motion was 57.7 degrees (81.7 percent functional use of pretransfer toe proximal interphalangeal joint arc of motion). There was no significant difference in the reconstructed proximal interphalangeal joint arc of motion for the handedness (p = 0.23), recipient digits (p = 0.37), or surgical experience in vascularized toe joint transfer (p = 0.25). The outcomes of different techniques of extensor mechanism reconstruction were similar in terms of extensor lag, arc of motion, and reconstructed finger arc of motion compared with the pretransfer toe proximal interphalangeal joint arc of motion. CONCLUSION: With this treatment algorithm, consistent outcomes can be produced with minimal extensor lag and maximum use of potential toe proximal interphalangeal joint arc of motion. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

A Novel Technique for Correcting Extensor Lag in Vascularized Toe PIP Joint Transfers.

The use of the vascularized second-toe proximal interphalangeal joint (PIPJ) for vascularized joint transfers (VJTs) allows for restoration of powerful pinch/grasp and range of movement of a PIPJ in the hand. However, because of the lack of central slip formation in the majority of toes, the reconstructed PIPJ often results in extension lag. Extension lag associated with poor central slip formation in the lesser toes can be corrected using central slip reconstruction methods such as the Stack method. However, such methods are often cumbersome and involve extensive dissection and soft tissue manipulation. We present a novel, reproducible, simple yet effective technique in recreating the insertion point of the extensor tendon in the reconstructed finger, hence correcting the issue of extensor lag in vascularized toe joint transfers. The crux of this technique empowers the surgeon with the ability to correct inherent extensor lag of toes in VTJs. This will hence nullify "toe PIPJ angles" as a preselection criteria in determining patients suitable for VJT, thus enabling more patients to benefit from VJTs.

Full-Length Finger Reconstruction for Proximal Amputation With Expanded Wraparound Great Toe Flap and Vascularized Second Toe Joint.

BACKGROUND: Most of the frequently used methods for finger reconstruction have their own limitations. Reconstruction of a full-length finger with normal appearance, in patients with proximal digital amputation, remains a challenge. METHODS: Between January 2002 and November 2013, a total of 86 fingers (60 patients) with proximal phalanx amputation were surgically repaired. A compound flap comprising an expanded wraparound flap from the great toe and a vascularized proximal interphalangeal (PIP) joint from the second toe was harvested to reconstruct a full-length finger. The flap was used to reconstruct the nail, skin, and the distal phalanx; the PIP joint was used to reconstruct the PIP joint. To attain normal length of the finger and right PIP joint positioning, an iliac bone graft was inserted into the distal-middle or proximal phalanx. RESULTS: All reconstructed fingers retained their viability and natural appearance and were of near-normal length with a normal PIP joint positioning; 12.8% (9/86) of the procedures required re-exploration owing to compromised circulation. Secondary procedures were required in 71% (61/86) of the cases. With the exception of 1 case, the donor-site complications were mild; the average range of motion at the other PIP joints was 52 degrees (-15 to -5 degrees of extension, 25-90 degrees of flexion). Approximately 80% of the normal functionality and 93% of the normal appearance with respect to aesthetics were restored. CONCLUSIONS: The full-length finger reconstruction procedure allows for construction of natural-appearing full-length fingers with normal PIP joint positioning and a near-normal functional recovery for proximal digital amputation. The operation is technically complex and time consuming and demands a skilled operator for successful outcomes.

Small, medium but not large arteries are involved in digital ulcers associated with systemic sclerosis.

OBJECTIVE: Digital ulcers (DU) are a burden in systemic sclerosis (SSc). Microangiopathy is a cardinal feature of SSc that plays a critical role in the development of DU. However, whether injury of medium or large vessels also contributes to DU in SSc remains controversial. METHODS: To measure concomitantly in SSc patients with and without active DU: (i) the Augmentation Index of the reflected wave (Aix_75) by radial applanation tonometry, an index of small and medium arterial function; (II) the aortic pulse wave velocity (PWV), a marker of large vessel injury (aortic stiffness). RESULTS: Sixty-three consecutive SSc patients were included (49 females, aged 60 [49-65] years, disease duration of 8.5 [5-13] years), including 10 (15.9%) with active DU. Patients with active DU versus those without had increased Aix_75 (35% [28-38] versus 28% [20-34], P=0.041) whereas no difference existed in PWV (7.0m/s [6.7-10.1] versus 7.6m/s [6.8-8.7], P=0.887), in systolic, diastolic, as well as aortic pulse pressure (P=0.126, 0.592, and 0.161, respectively). When compared to patients in the low tertile, patients having Aix_75 in the highest tertile had 10-fold more DU (OR=10.23; 95% CI 1.12 to 93.34, P=0.039). CONCLUSION: The presence of DU is associated with increased Aix_75 whereas there is no relation with PWV. These data suggest that small and medium arteries are involved in the occurrence of DU whether large vessel stiffness does not contribute. Whether Aix_75 is predictive of further DU remained to be studied.

Vascularised toe proximal interphalangeal joint transfer in posttraumatic finger joint reconstruction: the effect of skin paddle design on extensor lag.

UNLABELLED: Vascularised joint transfer (VJT) from the toe proximal interphalangeal joint (PIPJ) has been criticised for providing a limited range of motion (ROM) and significant extensor lag in reconstructed digits. The original technique includes the dorsal skin of toe PIPJ as a marker of joint viability, while a modified technique uses the skin flap of the great toe and the dorsal foot. This systematic review aimed to assess vascularised toe-to-finger PIPJ transfers with respect to functional outcomes, and in particular, whether a modified skin paddle design can improve extensor lag. METHODS: A MEDLINE search was performed. Studies were included if they present five or more vascularised toe-to-finger PIPJ transfers for posttraumatic reconstruction, and with the functional outcome data available. RESULTS: Seven studies including 92 VJTs met the inclusion criteria. The overall survival rate was 93.5%. Among the successful 86 VJTs, mean single-joint ROM was 37.4 ± 21.1°, with a mean extension lag of 31.8 ± 18.8° and a mean flexion of 69.2 ± 22.8°. The traditional group with the skin paddle taken from the dorsum of the toe PIPJ had a statistically significantly greater extensor lag than the modified group with the skin paddle harvested from the great toe and dorsal foot (37.8° vs. 17.1°, p < 0.001). The secondary variable of interest was age of the patient at time of transfer (children vs. adults). There was no significant difference in ROM between younger (≤16 years) and older patients (>16 years). CONCLUSIONS: This systematic review suggests that extensor lag may be improved by using the modified skin paddle design by harvesting it from the great toe and the dorsal foot. This effect may be mediated by the preservation of the native extensor tendon apparatus in the finger.

Improving the extensor lag and range of motion following free vascularized joint transfer to the proximal interphalangeal joint: Part 1. An observational and cadaveric study.

BACKGROUND: Extension lag is a common occurrence following free vascularized joint transfer reconstruction of the proximal interphalangeal joint, thus limiting the range of motion that is achievable. In this Part 1 study, the anatomical and biomechanical arrangements of the toe proximal interphalangeal joint extensor mechanism were investigated. METHODS: Twelve second toes from 12 fresh cadavers were dissected for examination of the extensor mechanism. Similar observations were performed in nine clinical cases. A total of 21 toes were therefore examined with dynamic and static testing. RESULTS: In 17 toes, the central tendon attenuated before inserting onto the middle phalangeal base (type I). In four toes, a thicker tendinous insertion analogous to a central slip was identified (type II). In type I toes, traction of the extensor digitorum brevis and digitorum longus did not correct the extensor lag. The extension lag decreased when the metatarsophalangeal joint was flexed passively or when both extrinsic and intrinsic tendons were pulled simultaneously. In type II toes, a full extension of the proximal interphalangeal joint was achieved when the extensor tendons were pulled with or without pulling the intrinsic tendons. In both types of toes, there was an increase in the extension lag caused by dorsal bowstringing when separated from the extensor sling. CONCLUSIONS: The lesser toe proximal interphalangeal joint adopts a naturally flexed posture for evolutionary reasons, with corresponding adaptations in extensor mechanism arrangements. The most significant limiting factor to full extension could be the presence of an attenuated central slip in the majority of toes.

Simultaneous reconstruction of extensor mechanism in the free transfer of vascularized proximal interphalangeal joint.

From a recent systemic review, vascularized toe proximal interphalangeal joint (PIPJ) transfer achieved an average arc of motion (AOM) of merely 37 degrees for finger PIPJ reconstruction. Despite the technical refinement over the past 3 decades, the resulting active motion of the reconstructed joint remains unpredictable and often fraught with extension lag. The technique for vascularized toe PIPJ transfer at our institute has evolved over the years to its current state, with simultaneous extensor mechanism reconstruction being a major component. During the transfer, the quality of extensor tendons on the recipient finger and donor toe are carefully evaluated. If the central slip of finger extensor is destroyed but the quality of lateral bands is adequate, centralization of lateral bands overlying the transferred PIPJ is performed. If there is acceptable central slip remnant at the proximal phalanx level, modified Stack procedure is performed for central slip reconstruction while leaving the lateral bands in continuity. If both lateral bands are poor, modified Stack procedure is performed unless the central tendon of the toe is strong enough to extend the PIPJ. From November 2008 to October 2010, 7 joints were transferred with this modified technique. The average follow-up was 18.2 months. The average active AOM of the transferred PIPJ was 56.4 degrees. The average extension lag of the toe PIPJ was 10.7 and 16.4 degrees before and after the transfer, respectively. Simultaneous reconstruction of extensor mechanism decreases the extension lag without sacrificing AOM of the transferred PIPJ.

Vascularised joint transfer in the management of recurrent giant cell tumour of the second metacarpal.

This paper presents the medium-term follow-up results (34 and 40 months, respectively) of two cases of recurrent giant cell tumour of the head of the second metacarpal, treated by marginal excision and reconstruction with a vascularised toe joint transfer. Both patients had painless, stable joints with excellent ranges of motion at the metacarpophalangeal joint of 80 degrees and 70 degrees , respectively, no degenerative changes and no recurrence of the tumours.

A systematic review of outcomes and complications of vascularized toe joint transfer, silicone arthroplasty, and PyroCarbon arthroplasty for posttraumatic joint reconstruction of the finger.

BACKGROUND: Posttraumatic conditions of the proximal interphalangeal and metacarpophalangeal joints require arthroplasty or fusion for pain control and functional improvement. Arthroplasty is increasingly becoming a preferred option for maintaining joint motion. However, a formal systematic review comparing the three currently available techniques-vascularized toe joint transfer, silicone, and PyroCarbon arthroplasty-has not been performed to critically evaluate outcomes and complication rates for these three options. METHODS: The authors used a formal systematic review of all available world literature (English and non-English). Data collection included active arc of motion as the primary outcome, and complication rates. RESULTS: Five hundred twenty articles were identified, reviewed, and screened through multiple inclusion/exclusion criteria. The mean proximal interphalangeal active arcs of motion for vascularized toe joint, silicone, and PyroCarbon were 37 +/- 9 degrees, 44 +/- 11 degrees, and 43 +/- 11 degrees, respectively. The mean metacarpophalangeal active arcs of motion for vascularized toe joint and silicone were 34 +/- 10 degrees and 47 +/- 16 degrees, respectively. Major complication rates requiring joint revision procedures for vascularized toe joint, silicone, and PyroCarbon were 29, 18, and 33 percent, respectively. CONCLUSIONS: Vascularized toe joint transfer has a worse active arc of motion and a higher complication rate when compared with silicone implant arthroplasty for both proximal interphalangeal and metacarpophalangeal joints. Early data suggest that PyroCarbon implants may be associated with higher rates of major complications. Given the lack of improvement in outcomes for posttraumatic finger joint reconstruction over the past 40 years, research efforts should focus on future development of novel arthroplasty devices.

Long-term results of free vascularized second toe joint transfers to finger proximal interphalangeal joints.

PURPOSE: To review the long-term clinical results of free vascularized second toe joint transfers for severely damaged finger proximal interphalangeal (PIP) joints. METHODS: Eleven joints in ten patients (1 woman, 9 men) were reviewed between 10 and 22 years after surgery. The average patient age at the time of the surgery was 32 years. Patients were evaluated at a mean follow-up time of 15 years; evaluation included range of motion of the transferred PIP joints and the remaining healthy second toe PIP joints, grip strength, finger and toe pain, finger function, gait disturbance, patient satisfaction, and x-ray changes. RESULTS: The mean active range of motion was 47 degrees that lacks 41 degrees extension and flexes to 88 degrees. The mean grip strength was more than 80% that of the nonaffected hand, and no finger pain or gait disturbances were reported. All patients had some extension lag and flexion contractures but most were satisfied with the clinical and functional results of surgery. In all joints, the joint spaces were preserved, although 1 patient had arthritis and 3 had osteophytes. CONCLUSIONS: It is important to prevent extension lag and flexion contracture to get better results from free vascularized second toe joint transfers. The transferred toe PIP joint is durable.

An anatomic comparison of venous damage resulting from 2 dorsal surgical approaches to proximal interphalangeal joint arthroplasty.

Proximal interphalangeal joint arthroplasties were performed on 40 toes of 10 fresh-frozen cadaveric feet. Twenty toes had a transverse elliptical incision of skin and extensor mechanism, and 20 had a longitudinal incision with transverse excision of extensor mechanism. Venous anatomy, including damage to the dorsal collateral veins, was noted. In the transverse-incision group, 14 (70%) of 20 toes had 1 dorsal vein transected, and 2 (10%) of 20 toes had both dorsal veins transected; in the longitudinal-incision group, no dorsal collateral veins were injured. As transverse incisions carry a high risk for damaging the dorsal collateral veins, and such damage may contribute to postoperative swelling, care should be taken to protect these veins. Longitudinal incisions are less likely to damage these venous structures.

Single pedicle vascularized double joint transfer: anatomic study of two models.

This study examined the anatomic structures that communicate between the tibial and fibular digital arteries of the second toe at the distal phalanx to identify a channel for retrograde blood flow from the dominant pedicle to the distal joint flap. We also assessed the feasibility of two models designed to mobilize toe joints to perform single pedicle vascularized double-joint transfer. The continuity of the vascular pathway in both models was demonstrated by microfil injection and angiographic study. The average mobile distance between the PIP joint and the MTP joint was 5.6 +/- 0.6 cm in model I and 5.1 +/- 0.4 cm in model II. The dissection and mobilizing procedures of the neurovascular pedicle are more complicated and extensive in model II than in model I, and the risk of jeopardizing vascularity of the distal joint flap is higher. Both models may be suitable to replace two adjacent metacarpophalangeal (MCP) joints in the hand or two nonadjacent MCP joints (excluding the thumb) separated by no more than one normal metacarpal.

Microarterial anatomy of the lesser toe proximal interphalangeal joints.

Successful free tissue transfer requires detailed knowledge of the pertinent microvascular anatomy of the donor site. The lesser toe proximal interphalangeal joints are a source of vascularized autologous tissue. In 20 adult cadaver feet, the arterial anatomy of the second, third, and fourth toes was studied using colored latex and India ink injection. The second, third, and fourth dorsal metatarsal arteries produced small or absent dorsal digital arteries in 72.5% of distal dissections. The proper digital arteries were 0.93 to 1.37 cm in length. An additional 2.3 to 2.83 cm of length can be gained by use of the plantar metatarsal arteries if the dorsal metatarsal or dorsal digital arteries are inadequate. The diameter of the medial proper digital arteries (range, 1.2-1.26 mm) was larger than the lateral proper digital arteries (range, 0.66-0.99 mm). The proper digital arteries of the lesser toes provide the predominant arterial supply of the proximal interphalangeal joints through a system of transverse and longitudinal arches.

Vascularized toe joint transfer to the hand.

From 1984 to 1993, 36 vascularized toe joints were transferred in 33 patients. The present study group excludes 3 toe joint transfers to elbow and temporomandibular joints and 4 toe joint to hand transfers lost to follow-up. The final study group includes 29 vascularized toe joint transfers in 27 patients, 21 males and 6 females. All were performed for posttraumatic reconstruction, except one transfer for congenital deformity. Follow-up averaged 32.4 months. Mean range of motion was 34 degrees in toe metatarsophalangeal joint to hand metacarpophalangeal joint transfers, 32 degrees in toe proximal interphalangeal joint to hand metacarpophalangeal joint transfers, and 24 degrees in toe proximal interphalangeal joint to hand proximal interphalangeal joint transfers. Although vascularized toe joint transfer is an alternative to arthrodesis, in order to have a greater range of motion than average, the patient must have well-functioning muscle and associated tendons effecting joint motion. Good results were obtained in two immediate free vascularized toe joint transfers to complex injuries involving loss of the metacarpophalangeal joint. We encourage toe joint transfer in selected complex hand injuries.

Free vascularized joint transfers in acute complex hand injuries: case reports.

The loss of function of the metacarpophalangeal joint is a significant disability. Simultaneous reconstruction of the soft tissue, extensor mechanism, joint, and flexor tendon in a complex hand injury is difficult and challenging. Free vascularized autogenous toe joint transplantation is a useful technique that provides not only joint replacement but also the soft tissue, extensor mechanism, and flexor tendon in more severe complex hand injuries. Two patients underwent immediate, free vascularized metatarsophalangeal joint transfer of the second toe to replace the long and ring finger metacarpophalangeal joint in acute complex hand injuries. The follow-up results at 16 months and 8 months postoperatively are presented.