Thumb reconstruction with a wraparound free flap according to the level of amputation

We surgically treated 37 thumbs amputated distal or proximal to the metacarpophalangeal (MCP) joint using a wraparound free flap from the great toe for the reconstruction. We studied the functional results of the procedure according to the level of amputation and the fixation angle of the iliac bone block. The cases were divided into 2 groups: group 1, which comprised 25 cases with the level of amputation distal to the MCP joint, and group 2, which comprised 12 cases with the level of amputation at or proximal to the MCP joint. Opposition of the reconstructed thumb to the other fingers was completely possible in all cases in group 1. In group 2 opposition was completely possible in 6 cases in which the iliac bone block was fixated into the position of 30 degrees flexion and 45 degrees internal rotation; in the remaining 6 cases, in which the graft was fixated into the position of 30 degrees flexion and 30 degrees internal rotation, complete opposition of the reconstructed thumb to the ring and little fingers was not possible. We found that amputation of the thumb proximal to the MCP joint is not an absolute contraindication for the wraparound free flap reconstruction. We recommend fixating the iliac bone block into 30 degrees flexion and 45 degrees internal rotation to obtain better functional outcome in cases with amputation at or proximal to the MCP joint.     

Second toe transfer for thumb reconstruction in multiple digit amputations including thumb and basal joint

Amputation of the thumb, including the basal joint, is a disabling injury that leaves limited reconstructive options. Three cases of multiple digit amputation including the thumb and basal joint are presented in which a second toe transfer was used to reconstruct the thumb. All patients have functional pinch with an average pinch strength of 27% of the opposite uninjured extremity. The average grip strength for two patients is 44% of the opposite hand. Average motion of the transfer at the MP, PIP, and DIP is 25 degrees, 37 degrees, and 9 degrees, respectively. Adduction and abduction are obtained, the degree depending on the site of proximal bony fixation. No patient has morbidity at the donor site and all are happy with their reconstruction. In selected cases we feel second toe transfer is an excellent choice to reconstruct the thumb amputated at a proximal level.     

足第二趾近侧趾间关节移植再造拇手指关节

目的 报道游离足第二趾近侧趾间关节移植再造拇手指关节临床疗效.方法 对手指关节损伤49例54指,采用吻合血管的足第二趾近侧趾间关节移植修复,其中再造掌指关节21指、近侧指间关节28指、远侧指间关节5指.全关节移植38指,半关节移植16指,术后观察其临床疗效.结果 移植关节49例54指全部成活.术后伤口均一期愈合.随访5～19个月,所有病例移植骨关节均愈合,临床愈合时间为4～8周,骨性愈合时间6～12周,移植关节均未出现退行性变,未出现骨不连及再骨折的现象.移植近侧指间关节屈曲活动度为35°～90°(平均65°);移植掌指关节者屈曲活动度为30°～75°(平均45°);移植远侧指间关节屈曲活动度为25°～65°(平均35°).参照关节活动度TAM/TAF评定标准评定,属优者23指,良者25指,可者5指,差者3指,优良率84%.近侧指间关节移植者效果最佳,其次是掌指关节,远侧指间关节移植者最差.结论 采用游离足第二趾近侧趾间关节移植修复拇手指关节缺损,功能恢复满意,可以较好的改善关节的功能.     

上肢高位离断再植的随访报告

目的　探讨上肢肩关节周围或上臂近端离断再植的适应证。方法　对 4例上肢高位离断患者的病史、术后功能的恢复进行了回顾性分析。其中 1例肩胛带离断者再植获得成功 ,在国内外尚属首次。结果　肩胛带离断再植者术后肩关节外展 4 5°,另 3例可达 90°。 4例肘关节、腕关节的伸屈运动基本达到正常范围 ;拇、手指屈伸活动恢复比较满意。术后 1年半 ,行手部功能重建术后 ,手的抓握及对指功能恢复。结论　上肢高位离断再植的适应证是肢体完整、缺血时间短 ,神经非根性撕脱伤 ,且患者年轻、全身状况好者 ,应尽量予以再植     

The results of replantation after amputation of a single finger

We reviewed fifty-nine consecutive cases of patients who had replantation of a single finger (excluding the thumb) after traumatic amputation, with an average follow-up of fifty-three months. Fifty-one (86 per cent) of the replanted fingers survived. Survival was found to be affected by the age of the patient, the number of vessels that were anastomosed, and the replantation experience of the surgeons. The survival rate was not affected by the gender of the patient, the mechanism of injury, or which finger was amputated. As compared with survival only, the functional results were most dependent on the level of amputation. The proximal interphalangeal joint in amputated fingers that were replanted distal to the insertion of the flexor superficialis tendon had an average range of motion of 82 degrees after replantation, while those amputated proximal to the insertion had an average range of motion of only 35 degrees after replantation. The average operating time was six hours and ten minutes, and the average time until the patient returned to work was 2.3 months. Based on this experience, it is our opinion that replantation of a single finger that was amputated distal to the insertion of the flexor superficialis tendon is justified, but that replantation of a single finger that was amputated proximal to this insertion is seldom indicated.     

One-stage reconstruction for amputated thumbs with melanoma

The reconstruction of amputated thumbs is difficult because of a poor prognosis, and the varying length and volume of the lost thumbs. Two patients underwent reconstruction of amputated thumbs in one stage with the use of a modified wrap-around flap procedure. An onychocutaneous flap from the big toe is suitable for partial defects, including the nail of the distal phalanx. A combined dorsalis pedis flap and wrap-around flap is also superior for total thumb reconstruction after amputation at the metacarpal phalanx involving the thenar region.     

Vertical locking of the metacarpophalangeal joint of the thumb.

Locking of the metacarpophalangeal (MP) joint of the fingers, though reported infrequently, is not rare in the literature. We will report two rare cases of the MP joint of the thumb locked in 90 degrees of flexion (vertical locking). The first case is a 21-year-old man, punched on his right thumb by his friend, who arrived with his thumb fixed in a flexed position. The X-ray images of the right thumb showed the proximal phalanx subluxation in the palmer side in a vertical position. The second case is a 35-year-old woman with her right thumb accidentally caught in the chain of a key-holder. The locking was easily reduced without anaesthesia in both cases. We assume the mechanism was that the flexion force on the MP joint led to subluxation and the locking occurred due to the tension of the collateral ligament caused by the volar prominence of the radial condyle.     

Finger reconstruction with a free neurovascular wrap-around flap from the big toe

From 1983 to 1998, 16 cases of finger reconstruction with a free neurovascular wrap-around flap from the big toe were treated. Fourteen cases were successful, and two cases failed. The authors reviewed these cases on the average of about 38 months after surgery. Pinch power was 51 percent of the unaffected normal hand, and two-point discrimination was 7.6 mm. The mean resorption of the grafted bone was 13 percent in width and 9 percent in length. There were no complications such as fracture of the grafted bone, nonunion, and pulp dislodgement. This procedure provided length, stability, and adequate sensibility for a functional pinch and grasp. Sensory return to the wrap-around flap on the thumb was often greater than for the same area on the opposite foot. The donor site of the wrap-around flap was acceptable, both aesthetically and functionally, and allowed the wearing of open-toed shoes by young women. Finger reconstruction with a wrap-around flap from the big toe yielded excellent cosmetic and functional results in cases involving amputation at the level of the metacarpophalangealjoints or distal to it. In addition, this procedure was an excellent choice for treatment in cases involving avulsion injuries of the fingers and reconstruction of soft-tissue defects after tumor excision.     

The influence of age and exercise on the mobility of hand joints: 3. thumb joints

Following our previous study about mobility of the three-phalangeal fingers we have measured flexion in the interphalangeal (IPP) and metacarpophalangeal (MPP) thumb joints as well as thumb opposition (hyperadduction) in university students (52 males and 49 females), seniors (30 males and 30 females) and pianists (21 males and 31 females). In the student control group we did not find difference between males and females or right and left hand, unlike in the previous study of three-phalangeal fingers. The MPP has greater flexion variability than the IPP joint. We have recorded greater limitation in all measured movements in seniors, in the thumb opposition significantly greater in males than in females. Pianists, on the other hand, always show greater thumb opposition, while greater flexion was significant only in the MPP joint in males. We did not record a difference between right and left hand in seniors or pianists.     

A complex reimplantation of digits: a case report.

In multiple finger amputations, microsurgical reconstruction should concentrate on the thumb, index, and middle fingers. The patient in the case report presented in this paper initially sustained an amputation of all of the digits on the left hand and an amputation of the right thumb. Both thumbs were amputated at the metacarpophalangeal joint. Initial replantation of the left thumb, index, and middle fingers and of the right thumb was carried out. The right thumb replantation failed and, after healing, the right great toe was transferred to the right hand. Subsequent to this, the patient developed useful function of all reconstructed digits. Twenty-one months after the first injury, both thumbs sustained new traumatic amputations 1.0 cm distal to the previous amputations. Both thumbs were replanted again successfully.     

Reconstruction of traumatic absence of the thumb in the adult by pollicization.

Amputation of the thumb is a severe handicap. In an emergency situation, thumb amputation must be treated by means of reimplantation when possible. If reimplantation cannot be performed or fails, several methods of thumb reconstruction can be used according to various factors. These include the number of surviving fingers and the level of the thumb amputation. Pollicization is the first choice for amputations proximal to the metacarpophalangeal joint when four and even three fingers are present. It is the easiest and safest operation that supplies the best results both from the motor and sensory points of view. Pollicization can be done even in an emergency situation in selected patients. The index finger is preferred because it can be pollicized without palmar scar or tendons, vessels, or nerves crossing over. If a damaged finger is present, it is preferred to the index finger to leave one more sound finger; a damaged finger can frequently be used, because the thumb is shorter than the other fingers, and although its mobility is very important at the trapeziometacarpal joint, it is less important at the metacarpophalangeal and interphalangeal joint levels. It is preferable to take as much second metacarpal bone as necessary to place the transferred second metacarpophalangeal joint at the position of the thumb metacarpophalangeal joint so that the tendons of the index interosseous muscles can be sutured to the intrinsic muscles of the thumb. According to this concept, the distal phalanx of the transferred finger should be amputated. In this manner, the new thumb will have a normal size, only two phalanges, only one extrinsic flexor, and normal insertion of the muscles of the thumb.     

Traumatized index finger pollicization for thumb reconstruction

PURPOSE: When the index finger is injured or severed in conjunction with a traumatic amputation of the thumb, transfer of the injured index finger can restore the important function of the thumb. The purpose of this study is to evaluate the results of the transfer of an injured index finger for traumatic loss of the thumb. METHODS: Seven patients treated by pedicled transfer of a traumatized index finger after amputation to the ipsilateral thumb were reviewed retrospectively. Postoperative evaluations included thumb range of motion, opposition and pinch function, grasp and pinch strength, sensation, a pick-up test, and a patient-rated appearance of the thumb and hand. Vascular patency of the traumatized index finger and thumb was evaluated in each patient prior to thumb reconstruction. RESULTS: After an average of 4 years of follow-up for surviving patients, all had excellent postoperative function and satisfactory results. The period between injury and thumb reconstruction ranged from 5 months to 4 years. All patients were men with a mean age of 43 years. Amputation levels included the metacarpophalangeal joint in 2 patients, the first metacarpal in 2 patients, and the proximal phalanx in 3 patients. All transferred traumatic index fingers survived without complications. CONCLUSIONS: Transfer of the injured index finger to the amputated thumb serves as an excellent adjunct for treatment of traumatic thumb amputations/crush injuries. Consistent results can be obtained while maintaining opposition and protective sensation after this procedure. However, technical demands are great, and initial injuries to the thumb and index finger ultimately determine the final outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.     

Thumb reconstruction with combination of the wrap-around flap prefabricated by medialis pedis perforator flap with nail bed and phalanx banked from the amputated thumb: A case report

Thumb reconstruction has been a very challenging issue for hand surgeons. In this report, we present a case of thumb reconstruction with combination of the wrap-around flap prefabricated by the medialis pedis perforator flap with phalanx and nail bed banked from the amputated thumb. A 22-year-old man suffered from the left thumb amputation as well as large soft tissue defect of hand and comminuted fracture in wrist due to a crush accident. The distal phalanx and nail bed of left thumb were exposed and no suitable vessels for microsurgical anastomosis could be found, resulting in the great difficulty of replantation. After debridement, nail bed of the amputated thumb was dissected and banked on the medial side of foot, while the distal phalanx was buried in the abdominal subcutaneous tissue. The fracture was fixed with an external fixation and the soft tissue defect was covered with a free anterolateral flap. Wound and bone healing was achieved 6 months after the initial treatment. Thumb was reconstructed with combination of the banked phalanx and a wrap-around flap prefabricated by the medialis pedis perforator flap and the banked nail bed. The postoperative course was uneventful with complications from both reconstruction and donor sites. The nail of the reconstructed thumb grew normally. Thumb oppositional function was rebuilt. The patient was satisfied with the aesthetic and functional outcome at 5-year postoperative follow-up. We propose that tissue banked from the nonreplantable amputated thumb could be used for secondary reconstruction with the technique of flap prefabrication.     

Distal thumb reconstruction using a mini wrap-around flap from the great toe.

We have used a great toe mini wrap-around flap for reconstruction of the thumb at, or distal to, the interphalangeal joint. Our series included 12 patients with traumatic amputations. A flap including the entire nail and most of the distal phalanx of the great toe was used. Eleven of the grafts survived. Sensibility was good with an average of 10 mm static two-point discrimination (range, 5-15) and there were no complaints of cold intolerance. All patients were pleased with the appearance of the thumb and there was no significant morbidity at the great toe donor site. The great toe mini wrap-around flap is an excellent reconstruction technique for selected patients with distal thumb amputations.     

Thumb reconstruction by the wrap-around method

Reconstruction of a thumb amputated distal to the metacarpophalangeal joint can be accomplished by the "wrap-around" procedure. The operative procedure calls for an iliac crest graft to replace the bone of the amputated thumb. A flap from the great toe with innervation and circulation intact, including the toenail as well as sensory nerve, is wrapped around an iliac crest graft in a single-stage reconstruction of the thumb. This procedure allows a nice aesthetic result; the nail is transferred, sensibility is restored to the amputated thumb through the transferred neurovascularly intact flap, and the procedure is done at a single sitting. Results to date have been excellent in ten patients.     

末节断指再植的功能评价

目的报道末节断指再植的远期功能效果.方法对38例42指末节断指再植成功者进行了平均2年3个月(10个月～4年6个月)的随访.结果拇指指间关节与手指远侧指间关节的平均主动活动度分别为49°和52°,两点辨别觉平均7.2mm.根据Tamai标准评价功能结果,42指中优25指,良17指.结论应强调精确吻合指神经的必要性,仅吻合一根指神经或不吻合指神经者感觉恢复较差;对累及关节的离断以关节融合为佳;再植后的萎缩为充盈不良或失用所致.     

应用改良(躅)甲瓣修复拇手指脱套伤

目的 探讨应用改良(躅)甲瓣修复各型拇、手指脱套伤的临床疗效.方法 根据不同损伤类型,采取4种方式修复18例28个脱套拇手指:①单侧改良(躅)甲瓣修复9例9个拇指近节中段以远脱套及3例3指近侧指间关节以远脱套;②单侧改良(躅)甲瓣加第二趾胫侧皮瓣修复2例2指全指脱套;③双侧改良(躅)甲瓣修复1例双侧拇指脱套;④双侧改良(躅)甲瓣加第二趾胫侧皮瓣与带感觉的超薄股前外侧皮瓣修复3例12指脱套.(躅)甲瓣切取时携带全部趾甲,保留(躅)趾趾底偏胫侧三角形皮瓣.结果 18例22块(躅)甲瓣及3块超薄股前外侧皮瓣均一期完全成活.15例获随访8～25个月,再造拇、手指外观接近健侧指体,运动及感觉恢复满意,供区无增生性瘢痕,跖底三角形皮瓣显著增宽,所有患者步行、跑、跳均无明显受限.结论 应用改良(躅)甲瓣修复拇手指脱套伤,不但受区可以获得接近健侧的良好外观和功能,而且可使供区损伤减少到最低限度,是目前显微重建拇、手指脱套伤的最佳术式之一.     

Reconstruction of the thumb amputation at the carpometacarpal joint level by groin flap and second toe transfer

IntroductionTraumatic loss of thumb at the carpometacarpal (CMC) joint level is very disabling to an individual. Pollicisation is the recommended technique of reconstruction for loss of thumb at this level. On occasions, injury to the rest of the hand or amputation of additional fingers may make pollicisation an impossible option. Microsurgical transfer of second toe is an option in such situations. Although many large series of toe transfers are available in the literature, no series deals exclusively with this subset of patients.Materials and methodsEight patients who had amputation of the thumb at or proximal to the CMC joint level were reconstructed by second toe transfer by us in the period 2002–2011. All had preliminary groin flap cover in the area of the thumb during the acute stage of treatment. Second toe with the metatarsal was transferred for thumb reconstruction after a mean duration of 3 months after flap cover. Patients were assessed for their ability to pinch, hold large objects and opposition achieved by Kapandji score. Average follow up is 4 years and 6 months with a minimum of 1 year.ResultsAll toe transfers survived. They reached their maximum functional potential by 1 year. All patients actively used the reconstructed thumb for day to day activities. Pinch was possible in all patients except two patients who did not have any fingers. Six of them registered grip strength of at least 50% of the opposite hand. When fingers were present, opposition was possible in all patients with Kapandji scores ranging from 5 to 8. Extent of usage was less in patients who did not have good function in other fingers.ConclusionSecond toe transfer is a viable option for reconstruction of thumb loss at or proximal to the CMC joint level. Proper planning of the preliminary flap cover determines the length of the thumb reconstruction. Strategic position of the transferred toe of adequate length and the functional status of the other fingers are important determinants of functional outcome.     

Experimental investigation of finger dynamics before and after metacarpophalangeal joint arthroplasty

PURPOSE: The purpose of this study was to quantify the changes in the arc of digital flexion before and after metacarpophalangeal (MCP) silicone arthroplasty with a 30 degrees preflexed design. METHODS: Index, middle, and ring fingers of 4 fresh-frozen cadaver hands were used. Each hand was attached (palmar side up) to a custom test apparatus. The tendon was drawn by a small winch-type servomotor. Micropotentiometers that were attached to the centers of rotation of the MCP, distal interphalangeal, and proximal interphalangeal joints measured angular displacement before and after MCP arthroplasty as a function of tendon excursion. The data were analyzed comparing the angle of flexion initiation and the angular displacement as a function of tendon excursion before and after joint arthroplasty. RESULTS: There were no statistical differences in the angles of the MCP joints at rest, the order of initiation of joint flexion, and the overall degree of flexion between the unoperated fingers and the fingers that had surgery. There was, however, a trend toward delay in flexion initiation, an increase in the MCP angle at rest, and a decrease in torque after implant arthroplasty. CONCLUSIONS: The decrease in initiation of flexion of the MCP joint, although not statistically significant, probably was related to the 30 degrees of preflexion built into the implant. We also noted a trend of decreased flexion at the MCP joint and increased flexion at the proximal interphalangeal and distal interphalangeal joints. This trend may be advantageous in the reconstruction of hands that initially have an MCP joint flexion deformity. TYPE OF STUDY/LEVEL OF EVIDENCE: to come.     

Collateral ligament injuries of the thumb metacarpophalangeal joint

The ulnar and radial collateral ligaments are primary stabilizers of the thumb metacarpophalangeal (MP) joint. Injury to these ligaments can lead to instability and disability. Stress testing is essential to establish the diagnosis. Complete tear is diagnosed on physical examination when the proximal phalanx of the thumb can be angulated ulnarly or radially on the metacarpal head by 30° to 35° with the MP joint in either zero degrees of extension or 30° of flexion. Lack of a firm end point or angulation measuring >15° on stress testing compared with the contralateral thumb MP joint are also indicative of complete tear. Partial ligament injuries may be managed nonsurgically, but complete tears are usually managed surgically. Various techniques are used to reattach the ligament to bone, including suture anchors and, less commonly, repair of midsubstance tears. Options for managing chronic injuries include ligament repair, ligament reconstruction with a free tendon graft, and arthrodesis of the MP joint.