Immediate free vascularized joint transfer from second toe to index finger proximal interphalangeal joint: a case report

The results of treatment of severe injuries to the proximal interphalangeal joint are unsatisfactory. The methods of joint reconstruction are discussed, including fusion, implant arthroplasty, perichondrial grafting and vascularized joint transfer. A patient is presented with a severe crush injury to the dorsum of the index finger with loss of skin and extensor tendon and proximal interphalangeal joint disruption. Immediate reconstruction of the finger is described using a composite free flap of skin, extensor tendon and proximal interphalangeal joint from the second toe. Follow-up at two years is described, demonstrating proximal interphalangeal motion and finger function.     

Autogenic heterotopic vascularized proximal interphalangeal joint transplantation in children

The proximal interphalangeal joint (PIP) joint is the most crucial joint for the functionality of a finger. For a child with complex injury of the hand every effort should be exercised to maximize function restoration. If the PIP joint is irreparably damaged, its reconstruction is indicated. The technique of autogenic heterotopic vascularized toe joint transplantation provides unique advantage of a composite transfer of skin, tendons, bone and joint alone with growth plate and its efficacy has been affirmed in children. It has been suggested that such transfers require intact flexor tendon to achieve satisfactory results, our experience however indicates quite the contrary. As evidenced by this report of a 7-year-old boy with abrasion and avulsion injury to his dominant right hand resulting in a complex defect with skin lose, extensor, flexor avulsion along with cominution of the PIP joint of his long finger. A surgical formulation of staged reconstruction scheme including an autogenic heterotopic vascularized toe joint transplantation led to complete functional restoration to his right hand.     

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.     

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.     

Current concepts: mallet finger

Loss of the extensor mechanism at the distal interphalangeal (DIP) joint leads to mallet finger also known as baseball finger or drop finger. This can be secondary to tendon substance disruption or to a bony avulsion. Soft tissue mallet finger is the result of a rupture of the extensor tendon in Zone 1, and a bony mallet finger is the result of an avulsion of the extensor tendon from the distal phalanx with a small fragment of bone attached to the avulsed tendon. Mallet finger leads to an imbalance in the distribution of the extensor force between the proximal interphalangeal (PIP) and DIP joints. If left untreated, mallet finger leads to a swan neck deformity from PIP joint hyper extension and DIP joint flexion. Most mallet finger injuries can be managed non-surgically, but occasionally surgery is recommended for either an acute or a chronic mallet finger or for salvage of failed prior treatment.     

Free vascularized toe-joint transfer in hand reconstruction: a series of 25 patients

Twenty-eight vascularized toe-joint transfers performed on 25 patients were reviewed. A number of different techniques were used: proximal interphalangeal joint or metacarpophalangeal joint reconstruction, one-stage double joint transfer, and interphalangeal thumb or trapezometacarpal joint replacement. Using these types of vascularized joint transfer allows one-stage composite transfer (including skin, bone, and extensor tendon) and provides rapid bone healing, potential growth in the young, good long-term cartilage preservation, normal lateral stability in pinch, and limited but useful range of motion (mainly at the proximal interphalangeal level).     

Experimental vascularized total joint autografts--a primate study

Autogenous vascularized and nonvascularized total joint transfers were studied in the hands of Macaca fascicularis monkeys. Nine second toe proximal interphalangeal joints were transferred as a vascularized free graft to the hand, and the excised finger joints were transferred to the foot as a nonvascularized free graft. The grafts were examined clinically and histopathologically at 16 weeks to 10 months. Two of the nonvascularized free grafts were amputated because of infection and necrosis. Three had chronic infections. The four surviving nonvascularized grafts demonstrated necrosis of the hyaline cartilage and degenerative changes. Of the nine vascularized joints, one developed a wound infection that required amputation, another failed at 2 weeks because of wound dehiscence, and the remaining seven survived with preservation of the hyaline articular surfaces. The experimental technique was designed to be easily applied to clinical use. A skin island is provided as a "patency/viability monitor." The extensor mechanism is included in the graft for early function.     

The mechanism of the intrinsic-minus finger: a biomechanical study

To demonstrate in the cadaver model that the sequence of extension of the flexed metacarpophalangeal and proximal interphalangeal joints of the intrinsic-minus finger can be explained on the basis of moment ratios about these joints, the engineering concept of free body analysis was applied. Intrinsic-minus fingers, i.e., fingers of a cadaver in which all forces exerted by the intrinsic muscles were removed, were observed to hyperextend maximally at the metacarpophalangeal joint before extension of the proximal interphalangeal joint began. Mathematical calculation of moments provides an explanation of this sequence. This study confirmed that, when an equilibrium of forces at the hyperextended metacarpophalangeal joint is reached, the proximal interphalangeal joint is incompletely extended. These forces include: (1) the proximal pull of the extensor tendon; (2) the distal loading of the extensor tendon by the flexor tendons; (3) the force preventing spanning of the laminae.     

The treatment of extensor lag of the middle finger following crushing–penetrating injuries of the metacarpophalangeal joint: case series

We aimed to introduce a surgical option for crushing–penetrating injuries around the metacarpophalangeal (MP) joint of the middle finger with extensor reconstruction of the interphalangeal (IP) joints. We also assessed the outcomes of patients using this surgical protocol. First, MP joint reconstruction was performed early (mean, 1.2 weeks after injury) using free autogenous cartilage or bone graft. We next performed a tendon transfer using a modified Brand method (M. Brand) at the same setting of extensor tendon tenolysis (mean, 4.7 months after injury) in order to extend the IP joints as a bonus for mutilating injuries of the hand. The mean arc of motion of each MP and IP joint increased after the M. Brand procedure. In one patient, worsening of palmar subluxation at the base of the proximal phalanx at the MP joint was observed. We found that tendon transfer by M. Brand achieves additional reconstruction for patients who have an IP joint extension lag after a crushing–penetrating injury around the MP joint. On the basis of these encouraging findings in this small series of cases, we recommend the M. Brand procedure after the MP joint stabilizes, as an optional bonus for mutilating injured hand.     

携带微型皮瓣的第二趾近趾间关节移植修复手指近指间关节缺损

目的 探讨采用携带微型皮瓣的游离第二趾近趾间关节移植修复手指近指间关节缺损的临床疗效.方法 对23例28指近指间关节缺损的患者,采用吻合血管的第二趾近趾间关节游离移植,其中全关节移植18指,半关节移植10指.结果 23例28指微型皮瓣全部存活,术后伤口均Ⅰ期愈合,无感染及骨髓炎发生.所有移植骨关节均愈合,临床愈合时间为4～8周,骨性愈合时间为6～10周;术后随访时间为5～16个月,平均9个月,移植关节均未出现退行性改变.1例2指半关节移植者术后移植关节向掌侧脱位,经手术再次矫形获得成功.移植近指间关节屈曲活动度为35°～90°,平均65°.参照关节活动度TAN/TAF评定标准评定:优10指,良14指,可2指,差2指;优良率为86%.结论 采用携带微型皮瓣的游离第二趾近趾间关节移植修复手指近指间关节缺损,功能恢复满意,关节活动可满足日常生活的需要,能很好地改善关节的功能.     

Immobilization of the mallet finger. Effects on the extensor tendon

Since the mallet finger that is treated with isolated splinting of the distal interphalangeal (DIP) joint can be moved freely proximal to the DIP joint, we sought to determine whether such motion might cause a tendon gap that could explain the extensor lag that often follows treatment. Experiments were performed on 32 cadaveric fingers with open mallet finger lesions, immobilizing either the DIP joint alone or both the DIP and PIP joints, while repeatedly flexing and extending the more proximal finger and wrist joints. For each experiment, the gap in the extensor tendon was measured. Joint motion proximal to the DIP joint and retraction of the intrinsics did not cause a tendon gap in a finger with a mallet lesion, supporting the convention that only the DIP joint needs to be immobilized.     

Treatment principles for proximal and middle phalangeal fractures.

After a proximal phalangeal fracture, optimal results are obtained by methods that permit active interphalangeal joint motion and tendon gliding during fracture healing. Typical apex palmar angulation of proximal phalangeal fractures demonstrates dorsal skeletal shortening and secondary incompetence of the extensor mechanism with PIP joint extensor lag. Apex palmar deformities of the middle phalangeal fractures demonstrate similar problems with skeletal shortening resulting in loss of distal joint extension. Proximal and middle phalangeal shaft fracture deformities rotate about their flexor tendons and their fibro-osseous tunnels. Functional restoration requires accurate skeletal realignment that restores normal skeletal length necessary for extensor tendon competence. A splint that holds the wrist in slight extension and all four finger MP joints in full flexion combined with active interphalangeal joint exercises form the essential elements of postoperative care.     

Treatment of mallet finger due to intra-articular fracture of the distal phalanx

When a mallet finger deformity results from an intra-articular fracture of the distal phalanx comprising more than one third of the articular surface, an accurate reduction of this fracture is necessary to prevent secondary degenerative arthritis. A technique for open reduction is described in which the distal interphalangeal joint is exposed by dividing the extensor tendon and permitting a precise reduction of the fracutre fragment. Elective division of the extensor tendon had not compromised the results.     

A conservative approach for proximal interphalangeal joint arthroplasty

Access to the proximal interphalangeal joint of the finger for arthroplasty is difficult without detaching its stabilizers or dividing the tendons that cross it, which then require repair and slow rehabilitation. We describe a method that conserves both, so facilitating post-operative rehabilitation.A C-shaped incision is made on the dorsum of the finger. The lateral bands of the extensor expansion are separated from the central slip proximally to the extensor hood. They are then retracted to expose the condyles of the proximal phalanx, which are excised. The PIP joint is then dislocated between the central slip and a lateral band allowing the remainder of the head to be excised. The middle and proximal phalanges are then prepared to accept the prosthesis. The prosthesis is then inserted and the joint is reduced. The lateral bands of the extensor mechanism are sutured back to the central slip before the skin is closed.     

Palmar dislocation of the proximal interphalangeal joint

Fifteen patients with palmar dislocations of the proximal interphalangeal (PIP) joint were reviewed 6 to 49 months after treatment (average 17.8 months). Disruption of the extensor mechanism, palmar plate, and one collateral ligament was found in all patients. The loss of static and dynamic joint support caused palmar subluxation, malrotation, and a boutonnière deformity. Two dislocations were irreducible, and three were associated with dorsal avulsion fractures from the middle phalanx. The serious nature of the injuries from this dislocation was initially unrecognized, and most patients were casually treated; delay from injury to referral averaged more than 11 weeks. Twelve of the 15 required surgery for joint reduction and tendon and ligament repair; three treated earlier were managed by closed reduction and percutaneous pinning. Joint alignment, comfort, and stability were restored, and all returned to full activities including heavy labor. However, a full range of PIP motion was not recovered in any case.     

Free vascularized whole joint transfer in children

Reconstruction of the traumatized finger joint with epiphyseal destruction has long been problematic. Since free vascularized whole joint transfer was introduced as a treatment for joint and epiphyseal destruction, this procedure has been selected as an alternative treatment because it may provide a growing epiphysis. We have reviewed our series of 19 joint transfers. Mean age at operation was 6.2 years (range 3 to 12). Average active range of motion was 31 degrees/61 degrees for the group with posttraumatic reconstruction (n = 12) and 21 degrees/43 degrees for the group with reconstruction of a congenital deformity (n = 7), with an overall average of 27 degrees/54 degrees. Average range of motion following transfer of an metatarsophalangeal (MTP) or metacarpophalangeal (MCP) joint to an MCP joint position was 39 degrees/75 degrees (n = 4); proximal interphalangeal (PIP) to PIP transfer was 22 degrees/39 degrees (n = 13); and PIP to MCP transfer was 38 degrees/51 degrees (n = 2). The proximal phalanges in MCP joints transferred to the MCP position grew an average of 7.0 mm, and the middle phalanges of joints transferred to the PIP position grew 4.3 mm. Almost normal growth was observed in all transferred joints except two that showed premature epiphyseal closure. Indications for this procedure and techniques to improve range of motion are described.     

Surgical treatment for boutonniere deformity of the fingers. Retrospective study of 47 patients]

Disruption or laceration of the central slip of the extensor tendon at the proximal interphalangeal (PIP) joint with volar displacement of the lateral bands can result in the so-called boutonniere deformity which includes loss of extension at the PIP joint and compensatory hyperextension of the distal interphalangeal (DIP) joint. Many procedures has been described in the literature and no standard treatment can be recommended. The authors reports a series of 47 cases of posttraumatic boutonniere deformity. The mean follow-up was five years. Majority of patients were males (38 males). The mean age was 41 years-old (17-82 y.o.). The etiology was in 23 cases a missed subcutaneous disruption of the central slip of the extensor tendon and in 24 cases an inappropriate treatment of laceration of the extensor apparatus at the dorsal aspect of the PIP joint. The involved digit was in seven cases the index finger, in 14 cases the long finger, in 14 cases the ring finger and in 12 cases the little finger. It is essential to distinguish the supple boutonniere deformity without or after physical therapy (34 cases) and the stiff boutonniere deformity even after a hand physical therapy program (13 cases). Results were assessed on pain and active range of motion of the PIP joint as well as the range of motion of the DIP joint. Supple boutonniere deformities, except one treated by an isolated distal tenotomy of the extensor tendon (1/34), was treated by a procedure of reconstruction of the extensor apparatus including resection-suture of the central slip and redorsalisation of the lateral bands when there was a DIP hyperextension with a moderate flexion deformity of the PIP joint, and (33/34) with 90% of excellent and good results. Poor results (4/33) were due in two cases to the absence of physical therapy, in one case to septic osteoarthritis and in one to secondary rupture of the suture. For the 13 stiff boutonniere deformities, when the PIP flexion deformity was moderate, a distal tenotomy performed to correct the DIP hyperextension was satisfactory in three cases with a useful result (20 degrees-70 degrees). For destroyed PIP joint (osteoarthritis), two silicone spacers were implanted with also a satisfactory result (30 degrees-70 degrees). In the eight remaining cases, a teno-arthrolysis was performed combined with a reconstruction of the extensor apparatus as described. Six poor results were obtained with arthritic PIP joints (which should have required initially silicone implants), and two fair results (30 degrees-60 degrees) with non-destroyed PIP joints. Supple boutonniere deformity must always be treated by initial physical therapy. Surgical procedure with reconstruction of the extensor apparatus is satisfactory if the PIP joint is normal. When there is PIP osteoarthritis, it may be beneficial to perform a two-stage technique with tenoarthrolysis followed hand therapy and a secondary reconstruction of the extensor apparatus as these last procedure give satisfactory results on a supple boutonniere deformity.     

Free vascularized toe joint transfer to the hand. A technique for simultaneous reconstruction of the soft tissue

Twelve patients underwent reconstruction of injured finger joints using our technique of a vascularized transfer of the second toe proximal interphalangeal joint. The age of the patients at operation ranged from 7 to 47 years and the postoperative follow-up was 9 to 48 months. All the joint transfers survived and united with resolution of the preoperative joint pain, deformity and instability. The average range of motion of the reconstructed joints was 59 degrees in the proximal interphalangeal and 54 degrees in the metacarpophalangeal joints. No patient complained of pain or functional deficits in the donor foot.     

Emergency repair of extensor tendon central slip defects with Oberlin's bypass technique: Feasibility and results in 4 cases with more than 5 years of follow-up

Treatment of soft tissues defects in the central slip of the extensor tendon at the proximal interphalangeal (PIP) joint is challenging because of the potential for stiffness and boutonniere deformity. The bypass procedure proposed by Oberlin for secondary injuries is an attractive solution. This salvage procedure uses a free tendon graft (palmaris longus) that is intercalated between the extensor indicis proprius muscle and the base of the middle phalanx. This study reports on the first cases of acute central slip defect treated in an emergency setting. Four patients with an average age of 37 years (range 11–69) were treated by the same surgeon using the bypass procedure. Clinical evaluations consisted of measuring the active range of motion in the PIP joint, QuickDASH, Total Active Motion (TAM) and strength with a Jamar^® dynamometer. All patients had reintegrated their injured finger into their body image within three months. At the last follow-up, the average active mobility was 0–5–76.5°. The functional outcomes were similar at nine months, with an average mobility of 0–13–72°. The two patients who were working at the time of injury were able to return to work in the third month. Various procedures such as tendon plasty, transfer or graft have been described in the literature for posttraumatic chronic boutonnière deformity. In cases where significant defects exist not only in the tendon, but the bone and skin, the bypass procedure is an effective approach to achieving satisfactory functional outcomes.     

Vascularized toe joint transplantation

The vascularized toe joint transfer is an alternative to arthrodesis. For optimal functional results, the patient must have normal-functioning muscle and associated tendons, effecting joint motion. Although vascularized toe joint transfer permits long-term preservation of joint architecture and cartilage, the goal of achieving normal range of motion for a reconstructed digit is still elusive. Reconstruction of the extensor mechanism can be worthwhile in selected patients because more useful motion can be achieved even if the result falls short of normal.