第二足趾外观塑形再造手指

目的 根据第二足趾的应用解剖特点,设计第二足趾再造手指的整形方法,使再造指外形和指甲更美观.方法 观测20只新鲜尸足第二足趾的底固有动脉的走行、分支和口径,以及20名健康成人第二足趾不同部位的周径差别和趾甲长度.临床行第二足趾移植再造手指15例18指,在再造术的同时,切取足趾末节跖侧方的梭形小皮瓣,面积约10 mm×20 mm,以近端为蒂逆转填充于足趾中节的纤细部,使再造指外观流畅.切除覆盖甲根的上甲皮约2 mm,使趾甲相对延长.结果 趾底固有动脉在远侧趾间关节平面恒定发出分支,这是末节趾腹小皮瓣的血供基础.第二足趾末节和中节的周径差别约为6 mm,中节纤细段长度约为21 mm.18指再造全部成活,中节和末节衔接平滑流畅,接近正常手指,指甲平均增长20%以上.结论 应用第二足趾末节趾腹皮瓣逆转整形和趾甲延长再造手指,能使再造指外形和指甲更美观,本术式特别适用于中节中份以远的手指再造.     

Double toe transfers

Ten double toe transfers for mutilating hand injuries have been studied. In two patients with total loss of all digits, pincer pinch was restored by the transfer of two separate toes, one to each side of the stump. Seven patients had survival of the thumb and a three-point chuck pinch was provided by transfer of a second toe plus a wrap-around flap over a bone graft to create a third, but stiff digit. One patient required three fingers and was treated by one single toe transfer and one double toe transfer.     

Nail flaps for microsurgical aesthetic reconstruction of thumb and donor site of great toe

Abstract

We describe a case of mutual transpositional transfers of toe and thumb in an attempt to restore the aesthetic appearance of the thumb with a deformity of the nail. The reconstructed thumb with the skin-nail flap from the great toe gave an excellent result both aesthetically and functionally, and the nail grew normally. The donor site of the great toe that was covered with the skin-nail flap from the thumb healed satisfactorily. This is another option for donor site management, the results of which are good, but the indications are under discussion.     

Nail flaps for microsurgical aesthetic reconstruction of thumb and donor site of great toe

Abstract We describe a case of mutual transpositional transfers of toe and thumb in an attempt to restore the aesthetic appearance of the thumb with a deformity of the nail. The reconstructed thumb with the skin-nail flap from the great toe gave an excellent result both aesthetically and functionally, and the nail grew normally. The donor site of the great toe that was covered with the skin-nail flap from the thumb healed satisfactorily. This is another option for donor site management, the results of which are good, but the indications are under discussion.     

The great toe

The biomechanics of the great toe and the pathologic anatomy of a hallux valgus deformity are presented. Patient evaluation is discussed. The section on decision making includes explanations of the Akin, chevron, and Mitchell procedures and instances for which the use of each is recommended.     

Modified great toe wrap for thumb reconstruction

Reconstruction of the traumatically amputated thumb can be achieved with good cosmetic and functional results utilizing autogenous bone graft and a neurosensory free wrap-around flap from the great toe. The donor area of the toe is modified to create a wrap-around flap to transfer innervated glabrous skin from the medial and lateral borders of the toe. This modification includes nail and nail matrix while preserving toe length and the important plantar weight-bearing skin of the great toe. A series of three patients who have undergone thumb reconstruction utilizing this method are reported. Postoperative follow-up averages 15 months. Sensory recovery is comparable to that reported in the literature; cosmetic appearance of the thumb and nail growth are good.     

Swollen great toe following trauma

The following case is presented to illustrate the roentgenographic and clinical findings of a condition of interest to the orthopedic surgeon. Initial history, physical findings, and roentgenographic examinations are found on this page. The final clinical and roentgenographic differential diagnoses are presented on the following pages.     

Foot morbidity following toe to hand transfers

Toe-to-hand transfers to replace missing fingers have become a common reconstructive practice in our clinic. The purpose of this article is to evaluate morbidity of the donor site on the foot following the transfer. A group of 72 patients were assessed; 95 feet were examined post-transfers, i.e., 23 patients had transfers from both feet. The groups were arranged according to the numbers of patients as follows: group A (37 cases), second toe from one foot; group B (17 cases), second toes from both feet; group C (6 cases) with wrap-around flap; and group D (5 cases), the whole big toe. This was followed by group E (7 patients), who had the combination of the second and third toes harvested simultaneously, the great toe or wrap-around flap in combination with harvesting the second toe from the same or contralateral foot. Scar quality of the donor site, standing on tiptoe and tiptoeing, discomfort after prolonged walking, stair climbing, need to change the shoe size, and participation in special activities, such as sports and overall patient satisfaction, were evaluated. The least significant problems occurred in patients with the second toe harvested, they had minimum complaints with static loading and minor complaints with dynamic loading. Patients with the second toes harvested from both feet also had minimum complaints with static loading and minor complaints in dynamic loading. More problems were observed with both static and dynamic loading in the patients with the great-toe transfer. The biggest troubles were reported by the patients with the wrap-around flap or in case of multiple toe transfers. Only one patient from the sample had to seek medical help of a specialist due to some problems following the toe harvest. In the retrospective subjective evaluation of patient satisfaction and benefits of the operation, all patients declared that they would undergo the reconstruction again despite the problems encountered at the donor site.     

Vascular anatomic variations in second toe transfers

To devise a new classification of vascular variations in second toe transfer we analyzed the anatomic details of the first dorsal metatarsal artery in 304 cases of second toe transplantation and the venous structure in 200 cases. According to location, the arterial vascularity was classified as superficial (18% of cases), intramuscular (54%), inframuscular (23%), and absent (5%). According to diameter, it was classified into large (16%), medium (64%), and small (20%). Based on branching pattern, the artery was classified into ramifying type (88%), main trunk (4%), and fine branch type (8%). The venous drainage of the second toe was categorized as greater saphenous vein main trunk type, greater saphenous vein fine branch type, dorsal digital vein main trunk type, and dorsal digital vein fine branch type. Variations of the first dorsal metatarsal artery are common. Classification should be done according to its location, diameter, and branching pattern at the toe web. Regardless of location, big vessels entering the second toe are the most important attribute for successful outcome.     

第二足趾血管神经蒂岛状皮瓣治疗躅趾背侧皮肤缺损

由于外伤、感染或其他原因导致躅趾背侧皮肤缺损时,常常伴有肌腱、趾骨和关节的外露,此时创面的覆盖是修复建外科比较棘手的问题.如果采用短缩截趾的方法[1],虽然简单,但是以牺牲重要足趾为代价,必然会影响足的外观和功能.应用交腿皮瓣等带蒂皮瓣的方法[2],虽然能获得创面的覆盖,但是存在需要二次手术、术后固定姿势不适等问题.应用游离皮瓣移植覆盖的方法存在技术要求高、手术风险大的缺点.近些年,足背带蒂皮瓣方法的应用撤告较多[3],但是由于供区位于明显的外露部位,手术往往造成明显的瘢痕,存在外观和功能的缺陷.2006年6月至2007年10月,我们应用以第二足趾胫侧趾血管神经为蒂的岛状皮瓣治疗8例躅趾背侧皮肤缺损患者,获得了良好的临床疗效,报告如下.     

Osteotomies of the great toe.

Patients are operated on for forefoot problems at an increasingly younger age, according to the author's experience. This has resulted in extra articular osteotomies of the first phalanx of the great toe, usually associated with other forefoot procedures. There exist several indications for these osteotomies. Among them are hallux valgus, hallux rigidus, and other forefoot disorders, such as rheumatoid diseases. Since 1984, the author has performed 2850 great toe osteotomies, allowing him to specify indications, to elaborate osteotomy procedures (varisation, derotation, shortening) and to devise appropriate implants, including specific staples and compression screws. A great toe osteotomy system has resulted in facilitating the execution of this very useful procedure.     

Osteoid osteoma of the great toe

Osteoid osteoma is a relatively common osteoblastic lesion of benign skeletal neoplasms and occurs most commonly in the cortex of long bones, especially the femur and the tibia. Radiological characteristics are a nidus that appears as a small, relatively radiolucent zone within an area of extensive reactive sclerosis. Clinically, the lesion presents with increasing pain, is worse at night, and is relived by nonsteroidal anti-inflammatory drugs (NSAIDs). Osteoid osteomas involving the phalanges of the toes are uncommon, and its accurate preoperative diagnosis is difficult due to the unique clinical and radiological features. The features in the phalanx of the toe are soft tissue swelling and a nidus frequently located in the cancellous without osteosclerosis. This article presents a case of a 22-year-old man with osteoid osteoma in his distal phalanx of the hallux. A needle biopsy of his great toe revealed a small number of bacteria, so he was initially treated for osteomyelitis but with unsatisfactory results. The particular characteristics of clinical and imaging findings supported a diagnosis of osteoid osteoma in the distal phalanx of the hallux. After surgical removal of the tumor, his symptoms resolved. The pathological examination confirmed the suspected diagnosis. In a patient with chronic foot pain that changes to become nocturnal and disappears with NSAID administration, it is important to include osteoid osteoma as a differential diagnosis. A detailed assessment of both clinical and radiological features can lead to the correct diagnosis, which must be confirmed with histopathological examination to ensure adequate excision.     

Painful sesamoid of the great toe

The painful sesamoid can be a chronic and disabling problem and isolating the cause can be far from straightforward. There are a number of forefoot pathologies that can present similarly to sesmoid pathologies and likewise identifying the particular cause of sesamoid pain can be challenging. Modern imaging techniques can be helpful. This article reviews the anatomy, development and morphological variability present in the sesamoids of the great toe. We review evidence on approach to history, diagnosis and investigation of sesamoid pain. Differential diagnoses and management strategies, including conservative and operative are outlined. Our recommendations are that early consideration of magnetic resonance imaging and discussion with a specialist musculoskeletal radiologist may help to identify a cause of pain accurately and quickly. Conservative measures should be first line in most cases. Where fracture and avascular necrosis can be ruled out, injection under fluoroscopic guidance may help to avoid operative intervention.     

Osteoid osteoma of the great toe

Osteoid osteoma is a benign tumor which most commonly affects adolescents and young adults. Although this lesion occurs predominantly in the lower extremities, it has been described in the great toe only once before in medical literature. This bone lesion causes acute localized pain, worse at night, and it is relieved by aspirin or other anti-inflammatory medications. Treatment of choice is en bloc excision of the lesion. The prognosis with appropriate diagnosis and treatment is excellent.