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Clinical effect of thumb finger reconstruction using dorsal foot flap transplant for treating thumb defects
Medical Hypotheses 134 (2020) 109435
Contents lists available at ScienceDirect
Medical Hypotheses journal homepage: www.elsevier.com/locate/mehy
Clinical effect of thumb finger reconstruction using dorsal foot flap transplant for treating thumb defects Z. Xuefeng1, G. Jian1, D. Jiayue, Z. Chuchen, W. Shenglin, Y. Xiao'en
T
⁎
Department of Plastic Surgery, Lishui People’s Hospital, Lishui, Zhejiang Province, China
A R T I C LE I N FO
A B S T R A C T
Keywords: Dorsal foot flap Thumb finger reconstruction with toe transplant Thumb finger defect Clinical effect
It was found that conventional toe graft alone could not meet the patients' needs for wound repair, so we hypothesized that it would be more effective to treat thumb and finger defect by toe graft with dorsalis foot flap. This prospective study was conducted in 104 thumb defect patients to investigate the clinical effect of thumb reconstruction using toe graft with dorsal foot flap for the treatment of thumb defects. These patients were randomly divided into the dorsal foot group and the control group by randomized double-blind method, with 52 patients in each group. The second toe was used for thumb reconstruction transplant in both the groups. After thumb reconstruction, the abdominal pedicled flap was used to repair the surgical wound in the control group whereas the dorsal foot flap was used to repair the surgical wound in the dorsal foot group. Three months after surgery, the efficacy of surgical treatment, evaluation of two-point discrimination, postoperative complications, function of reconstructed thumb, operation time, and hospitalization time were recorded and compared between the two groups. MHOQ questionnaire was used to evaluate and compare the patients' satisfaction with finger reconstruction in both the groups. The surgical therapeutic effect, the function of the reconstructed thumb, and satisfaction with finger reconstruction were significantly higher in the dorsal foot group compared to the control group (all p < 0.05). The postoperative two-point discrimination, postoperative complication rate, operation time, and hospitalization time of patients in the dorsal foot group were significantly lower compared to the control group (all p < 0.05). Thumb finger reconstruction using the second toe transplant with dorsal foot flap had a beneficial effect on thumb defect patients. It can effectively improve finger function and sensory recovery of patients while reducing complications.
Introduction and hypothesis
this is an ideal method for thumb reconstruction, with a high success rate [6]. However, some studies have also suggested that conventional toe transplant alone cannot meet the patients' need for wound repair in thumb injuries with large skin defects [7]. Therefore, a previous study had proposed the use of a toe transplant with a dorsal foot flap to reconstruct and repair the thumb defect in patients [8]. Some studies have indicated that since the thickness of dorsal foot flap is relatively thin and its structure is very similar to the skin of hands along with a relatively fixed vascular trend, it is conducive to the recovery of patients' hand function [9]. However, another study has shown that toe transplant with a dorsal foot flap can cause great damage to the foot and hence it is not recommended [10]. In the present study, we hypothesized that second toe transplant with a dorsal foot flap for thumb reconstruction could be effective for thumb defect patients. We carried out this treatment and compared its
As one of the main functional organs of the human body, hands are important in both labour and communication [1]. Due to work-related and other incidences, people often suffer from accidental hand injuries, which are likely to cause thumb mutilation. This not only has a serious impact on the hand aesthetics and functions but may also have a certain negative impact on the patients' psychology [2,3]. Thumb injuries often cause damage to the nail bed and the perithyroid soft tissue which makes it difficult to repair [4]. For such patients, improper treatment is very likely to cause a severe dysfunction of the hand. Therefore, timely and effective treatment is of great clinical significance for patients with thumb defect [5]. Currently, in clinical practice, second toe transplant is often used for the treatment of thumb defects and many studies have concluded that
⁎
Corresponding author at: Department of Plastic Surgery, Lishui People’s Hospital, No. 15 Dazhong Street, Liandu District, Lishui 323000, Zhejiang Province, China. E-mail address: [email protected] (Y. Xiao'en). 1 Co-first authors, contributed equally to this work. https://doi.org/10.1016/j.mehy.2019.109435 Received 31 July 2019; Received in revised form 8 October 2019; Accepted 14 October 2019 0306-9877/ © 2019 Elsevier Ltd. All rights reserved.
Medical Hypotheses 134 (2020) 109435
Z. Xuefeng, et al.
outcome with a control procedure of abdominal pedicled flap for thumb finger reconstruction following the second toe transplant.
to the arteriae digitsles plantares. The dorsal cutaneous nerve and the great saphenous vein was included when the flap was dissociated. During the transplant, the toe-metacarpal bone was fixed with Kirschner wire, the extensor flexor tendon was repaired and the proper artery of the toe and thumb was anastomosed. Subsequently, the great saphenous vein and cephalic vein of dorsal foot flap were anastomosed, the dorsal foot nerve and radial nerve were anastomosed, and finally, the wound was sutured. (3) Postoperative fixation was performed with a plaster on the hand and warmth was provided to the hand by light illumination. Anti-thrombotic, antibiotics, and anti-spastic treatment were given, and the blood flow in the hand of the patient was closely monitored. If blood flow problems were found, timely treatment was given.
Materials and methods General data This study was carried out on 104 patients with thumb defects, admitted to Lishui People’s Hospital from July 2013 to May 2017, including 58 male patients and 46 female patients. The average age of all patients was (28.3 ± 4.5) years. Patients were randomly divided into the dorsal foot and the control groups by randomized double-blind method, with 52 patients in each group. Patients in both groups received the second toe transplant for thumb reconstruction. Patients in the control group received the abdominal pedicled flap while patients in the dorsal foot group received the dorsal foot flap after thumb reconstruction to repair the surgical wound.
Observation indicators (1) Three months after surgery, the curative effect of the two groups was evaluated and compared [11]. The curative effect was divided into markedly effective (survival of all hand skin grafts after operation; normal finger function), moderately effective (skin grafts survival area ≥ 60%; normal finger function) and ineffective (skin graft necrosis after the operation; no improvements in finger dysfunction). The total efficacy of treatment = (markedly effective cases + moderately effective cases)/total cases * 100%. (2) Two-point discrimination was evaluated and compared between the two groups before and after the operation (at the pulp of the thumb). (3) The complications in the two groups were recorded and compared. The complications included arterial crisis, venous crisis, local erosion of the skin graft, infection and inflammation (including skin grafting and donor areas), and nerve injury of the hand tissue. (4) The function of the reconstructed thumb was scored and compared between the two groups. The comparison criteria were as follows: 5 points – the reconstructed thumb moved normally without effort; 3–4 points – the finger moved normally but with slight pain; 2 points – the finger moved barely with pain; and 1 point – the finger did not move. The higher the score, the better the functional recovery. (5) The operative period and duration of hospitalization of the two groups were recorded and compared. (6) The MHOQ questionnaire was used to evaluate and compare the satisfaction levels in patients of the reconstructed finger. Satisfaction was divided into very satisfied, satisfied, and unsatisfied [12]. Total satisfaction was calculated as total satisfaction = (very satisfied + satisfied)/total case * 100%. Therapeutic efficacy and postoperative complications were the main evaluation indicators while the rest were secondary observation indicators.
Inclusion and exclusion criteria Inclusion criteria: Patients meeting the diagnostic criteria for thumb defect (including complete thumb defect and partial thumb defect); patients aged 20–40 years; patients who met the surgical indications (good health conditions with no other concurrent shock; eligible for thumb reconstruction; and a thumb defect injury in accordance with grade I-V). Exclusion criteria: Patients with surgical contraindications (including patients with severe infectious diseases and allergies to anesthetics); patients with severe coagulation dysfunction (decrease or disappearance of plasma factor activity with symptoms of subcutaneous hemorrhage); patients with severe hepatorenal dysfunction (increased transaminase and urea nitrogen and serum creatinine); patients with immune system diseases; patients who refused surgery; and patients with communication or cognitive impairment. All patients and their families agreed to participate in the study and signed the informed consent document. This study has been approved by the Ethics Committee of Lishui People’s Hospital. Operative procedure Before the operation, the injured thumb was debrided thoroughly and the stump of the thumb was trimmed. (1) For the patients in the control group, finger reconstruction using second toe transplantation was combined with a traditional abdominal pedicled flap to repair the surgical wound. The first step was designing the skin flap according to the patient's injury by considering the projection line of the superficial abdominal artery as the axis. First, the skin was cut along the pedicle to expose the subcutaneous toe and then the fascia perforating branch of the abdominal wall was located. The distal end of the flap was cut retrograde from the shallow layer of the deep fascia. The deep fascia around the abdominal pedicled skin flaps was removed carefully. Subsequently, the second toe was removed. After removal, the metacarpal bone of the toe was fixed with Kirschner wire and the proper artery of the toe and thumb was anastomosed. The extensor flexor tendon was then repaired and the reconstructed vasculature of the thumb was anastomosed with the proper artery of the thumb. The nerve pedicle with an abdominal pedicled flap was anastomosed with the nerve of the thumb and the reconstructed vein was anastomosed with the subcutaneous vein of the thumb which was followed by direct suturing. (2) Patients in the dorsal foot group, on the other hand, were treated by thumb finger reconstruction using second toe transplant with a dorsal foot flap. First, the dorsal foot flap was removed according to the thumb defect of the patient. A longitudinal incision was made on the dorsal foot flap and the arteries and veins on the dorsal foot were all dissociated. The inner and outer edges of the dorsal foot flap were then cut open and the flap was dissociated along the dorsal metatarsal artery
Statistical methods SPSS19.0 software (Bizinsight Intelligence (Beijing) Information Technology Co., Ltd.) was used to analyze the experimental data. Counting data were expressed as percentages and the differences were calculated by chi-square. Measurement data were expressed by mean ± standard deviation. The measurement data between the two groups were compared using Student’s t-test for independent samples and paired Student’s t-test for comparison within the group before and after the treatment. The differences were considered significant when p < 0.05.
Results Comparison of general data There were no significant differences in gender, age, cause of thumb injury, history of diabetes mellitus, and anaemia between the two groups (all p > 0.05, Table 1). 2
Medical Hypotheses 134 (2020) 109435
Z. Xuefeng, et al.
Table 1 Comparison of general data (n, %). Control group (n = 52)
Dorsal foot group (n = 52)
Gender Male Female
28 (53.85) 24 (46.15)
30 (57.69) 22 (42.31)
Age (year) ≤28 > 28
24 (46.15) 28 (53.85)
25 (48.08) 27 (51.92)
BMI (kg/m2) ≤23 > 23
25 (48.08) 27 (51.92)
24 (46.15) 28 (53.85)
Diabetes History Yes No
10 (19.23) 42 (80.77)
9 (17.31) 43 (82.69)
Anemia history Yes No
9 (17.31) 43 (82.69)
Injury causes Mechanical injury Burn Other Liver function index Total serum protein (g/L) Glutamic-pyruvic transaminase (μmol/L) Total bilirubin (μmol/L) Renal function index Creatinine (μmol/L) Serum urea (μmol/ L) Trioxypurine (μmol/ L)
χ2
p
0.156
0.623
0.038
0.844
0.039
0.844
0.064
0.800
0.070
0.791
0.060
0.971
Fig. 1. Two-point discrimination before and after the operation. *p < 0.05.
8 (15.38) 44 (84.62)
25 (48.08) 13 (25.00) 14 (26.92)
26 (50.00) 12 (23.08) 14 (26.92)
72.29 ± 2.02
72.23 ± 2.01
0.152
0.880
28.31 ± 4.46
27.82 ± 4.42
0.563
0.575
11.14 ± 2.05
11.22 ± 2.07
0.198
0.843
66.08 ± 3.14 5.56 ± 0.33
67.11 ± 3.01 5.51 ± 0.28
1.708 0.833
0.091 0.467
261.36 ± 10.33
262.29 ± 9.89
0.469
0.640
the two-point discrimination in the two groups before the operation (p = 0.936). However, the two-point discrimination decreased significantly in both groups after surgery with the two-point discrimination in dorsal foot group significantly lower compared to the control group (p < 0.001, Fig. 1). Complications in the two groups of patients In the control group, there were 4, 3, 2, 4, and 2 patients with arterial crises, venous crises, local erosion of skin graft, infection and inflammation, and nerve injury of hand tissue, respectively and the total incidence of complications was 28.85%. In the dorsal foot group, the number of patients with the arterial crisis, venous crisis, local erosion of skin graft, infection and inflammation, and nerve injury of hand tissue were 1, 1, 0, 2, and 0, respectively with a total incidence of complications of 7.69%. The incidence of complications in the dorsal foot group was significantly lower compared to the control group (p < 0.05, Table 3).
Comparison of clinical therapeutic effect Functional score of reconstructed thumbs three months after the operation The number of markedly effective, moderately effective, and ineffective therapeutic effect in the patients of the control group was 18, 19, and 15, respectively with the total efficacy at 71.15%. The number of markedly effective, moderately effective, and ineffective therapeutic effect in the patients of the dorsal foot group was 23, 25, and 4, respectively with the total efficacy at 92.31%. The total efficacy of the treatment in the dorsal foot group was significantly higher compared to the control group (p < 0.05, Table 2).
The functional score of the reconstructed thumb in the control group was (4.37 ± 0.64), 3 months after the operation while it was (5.87 ± 0.32) in the dorsal foot group. The thumb function score in the dorsal foot group was significantly higher compared to the control group, 3 months after operation (p < 0.001, Fig. 2). Comparison of the operative period and hospitalization time The operative period and hospitalization time of the control group were (49.54 ± 10.31) min and (22.14 ± 7.47) d, respectively while the operative period and hospitalization time of the dorsal foot group were (35.18 ± 9.05) min and (12.69 ± 4.58) d, respectively. Both parameters in the dorsal foot group were significantly lower compared to the control group (both p < 0.05, Table 4).
Two-point discrimination before and after the operation In the control group, the preoperative and postoperative two-point discriminations were (18.21 ± 2.56) mm and (7.43 ± 2.11) mm, respectively. In the dorsal foot group, the preoperative and postoperative two-point discriminations were (18.17 ± 2.47) mm and (5.04 ± 1.15) mm, respectively. There was no significant difference in
Table 3 Complications in the two groups of patients (n, %).
Table 2 Comparison of clinical therapeutic effect (n, %). Therapeutic effect
Markedly effective Moderately effective Ineffective Total efficacy
Control group (n = 52)
Dorsal foot group (n = 52)
18 (34.62) 19 (36.54)
23 (44.23) 25 (48.08)
15 (28.85) 37 (71.15)
4 (7.69) 48 (92.31)
χ
2
1.007 19.221
Complications
Control group (n = 52)
Dorsal foot group (n = 52)
χ2
p
Arterial crisis Venous crisis Local erosion of skin graft Infection and inflammation Nerve injury of hand tissue Total incidence of complications
4 (7.69) 3 (5.77) 2 (3.85) 4 (7.69) 2 (3.85) 15 (28.85)
1 1 0 2 0 4
1.951 1.080 2.039 0.708 2.039 7.792
0.163 0.299 0.153 0.400 0.153 0.005
p
0.316 < 0.001
3
(1.92) (1.92) (3.85) (7.69)
Medical Hypotheses 134 (2020) 109435
Z. Xuefeng, et al.
Table 5 Satisfaction evaluation of reconstructed finger (n, %). Satisfaction
Control group (n = 52)
Dorsal foot group (n = 52)
χ2
p
Very satisfied Moderately satisfied Dissatisfied Total satisfaction
21 15 16 36
26 (50.00) 23 (44.23) 3 (5.77) 49 (94.23)
0.971
0.325
9.070
0.003
(40.38) (28.85) (30.77) (69.23)
the functional recovery of fingers are poor [16,17]. Another study which evaluated the effect of dorsal pedis flap in repairing finger defect showed that this method not only had a high survival rate of skin graft but also improved the blood flow and promoted the recovery of hand function [18]. Other studies suggest that dorsal pedis skin flaps can repair the defective skin of patients in addition to the damaged muscles since they have extensor digitorum tendons which effectively promote the functional recovery in patients [19]. Another study has shown that since sensory disorders could make coordinated movements difficult, the main issue of finger reconstruction in the clinic is whether patients can receive an improved finger function and sensation [20]. Subsequent studies have indicated that repairing the reconstructed thumb with dorsal foot flap could restore the two-point discrimination and improve the function of the ventral part of the toe, and could make the reconstructed thumbnail look natural [7,21]. We have reported similar observations in our study. Subsequently, we have further compared the incidence of postoperative complications between the two groups. The results showed that the incidence of postoperative complications in patients in the dorsal foot group was significantly lower compared to the control group, which suggested that the reconstruction of thumb with dorsal foot flap could effectively reduce postoperative complications in patients. We analyzed the causes of complications and found that, for example, the causes of arteriovenous crises were mainly due to tortuous vessels caused by hematoma compression and vascular pedicle compression [22]. A previous study indicated that the advantage of this surgical method is that the toe graft and the repaired skin flap share the same vascular pedicle requiring only one set of vascular system anastomosis during the operation, and thus, reduces the occurrence of a vascular crisis [23]. Combined with other complications, we found that the complications were related to the blood supply of the flap, the location of the skin graft, and the dressing and other factors, which can be studied in detail in the future. Finally, we compared the two groups of patients' satisfaction with finger reconstruction and observed that the satisfaction of patients in the dorsal foot group was significantly higher compared to the control group. This suggests that thumb defect patients still have a high degree of acceptance for finger reconstruction by toe transplant with dorsal foot flap. In conclusion, thumb finger reconstruction using second toe transplant with dorsal foot flap is effective and can effectively promote finger function and sensory recovery in thumb defects of patients. It also reduced the incidence of complications and could be used more frequently for similar thumb injuries. However, there are some limitations to this study. For example, we did not conduct a multivariate analysis of the incidence of complications. Therefore, this conclusion needs further analysis and validation. In addition, arm flap and other repair methods [24], were not evaluated for a comprehensive comparison to determine whether the second toe transplant with the dorsal foot flap is the most appropriate surgical method for thumb finger
Fig. 2. Functional score of reconstructed thumbs 3 months after the operation. *p < 0.05.
Satisfaction evaluation of reconstructed finger In the control group, 21 patients were very satisfied, 15 were moderately satisfied, and 16 were dissatisfied with the finger reconstruction with total satisfaction in 69.23%. In the dorsal foot group, 26 were very satisfied, 23 were moderately satisfied and 3 were dissatisfied with the finger reconstruction with total satisfaction of 94.23%. The satisfaction degree in the dorsal foot group was significantly higher compared to the control group (p < 0.05, Table 5).
Discussion Due to complex functions of the hand, the repaired fingers should not only have a relatively good function but also look good aesthetically. This leads to higher difficulty in the repair and reconstruction of fingers injured due to accidents [13,14]. In clinical practice, toe transplant has always been the choice of treatment to repair the thumb injury of the hand [15]. However, there is some degree of controversy about the choice of skin flaps for soft tissue repair after toe reconstruction. Therefore, in our study, we compared the effect of thumb finger reconstruction with dorsal pedicled flaps to traditional abdominal pedicled flaps. First, we compared some indicators in the two groups of patients. The results showed that the total efficacy of surgical treatment and the score of surgical reconstruction function in the dorsal foot group were significantly higher compared to the control group, while the operative period and hospitalization time were significantly lower in the dorsal foot group. Two-point discrimination decreased significantly in both the groups after surgery but was significantly lower in the dorsal foot group compared to the control group. This suggests that irrespective of whether abdominal pedicled skin flap or dorsal pedicled skin flap was used, both have some treatment efficacy in patients with thumb defect. However, toe transplant with dorsal pedicled skin flaps has a significantly higher beneficial effect. Some studies have indicated that although this method has a high survival rate, the hospital stay and recovery times are longer, and the sensory recovery of the skin flaps and Table 4 Comparison of the operative period and hospitalization time.
Operative period (min) Hospitalization time (d)
Control group (n = 52)
Dorsal foot group (n = 52)
t
p
49.54 ± 10.31 22.14 ± 7.47
35.18 ± 9.05 12.69 ± 4.58
7.548 7.777
< 0.001 < 0.001
4
Medical Hypotheses 134 (2020) 109435
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reconstruction. These could be a future aspect that could be explored.
the level of the proximal metacarpal bone. Microsurgery 2009;29(3):178–83. [9] Kobayashi K, Fukasawa K, Masuyama N. The observation of the vein distribution of a partial toe-transfer flaps with a short vascular pedicle. J Hand Surg Asian Pac 2018;23(2):227–31. [10] Jin GZ, Ju JH, Li L, et al. Application of toe transplantation combinw with skin flaps of the perforating branch of lower abdominal fascia in thumb reconstruction. Chin J Aesthetic Med 2010. [11] Hosseinian MA, Gharibi Loron A, Nemati Honar B. Reconstruction of the plantar toe with a distal reverse instep sensory island flap. Microsurgery 2018;38(6):667–73. [12] Ebrahimzadeh MH, Birjandinejad A, Kachooei AR. Cross-cultural adaptation, validation, and reliability of the michigan hand outcomes questionnaire among persian population. Hand Surg 2015;20(1):25–31. [13] Zhou X, Li XR, Qing J, Jia XF, Chen J. Outcomes of the six-strand M-Tang repair for zone 2 primary flexor tendon repair in 54 fingers. J Hand Surg Eur 2017;42(5):462–8. [14] Harada M, Mura N, Takahara M, Takagi M. Complications of the fingers and hand after arthroscopic rotator cuff repair. Open Orthop J 2018;12:134–40. [15] Woo SH, Lee GJ, Kim KC, Ha SH, Kim JS. Cosmetic reconstruction of distal finger absence with partial second toe transfer. J Plast Reconstr Aesthet Surg 2006;59(4):317–24. [16] Du ZG, Xiu XL, Wang W, et al. Abdominal random single pedicled flap of three leaves for the treatment of multiple finger skin defects. Chin J Orthopa Trauma 2012;25(7):579–81. [17] Huang SR, Li XY, Wang H, Liu JT. An improved technique for repairing hand defects with abdominal pedicled flaps. J Southern Med Univ 2011;31(10):1771–3. [18] Li M, Luo ZH, Gu H, Ma L, Yang Y, Zhang Z. Free croin flap for repairing defects of donor after toe tissue transplantation. Chin J Repar Reconst Surg 2016;30(2):215–8. [19] Koshima I, Urushibara K, Inagawa K, Hamasaki T, Moriguchi T. Free medial plantar perforator flaps for the resurfacing of finger and foot defects. Plast Reconstr Surg 2001;107(7):1753–8. [20] Ma ZG, Guo YJ, Yan HJ, Li QM, Ma B. Long-term follow-up on the donor foot after thumb reconstruction using big toe wrap-around flap in two different operation methods. Indian J Surg 2017;79(1):6–12. [21] Wavreille G, Cassio JB, Chantelot C, Mares O, Guinand R, Fontaine C. Anatomical bases of the second toe composite dorsal flap for simultaneous skin defect coverage and tendinous reconstruction of the dorsal aspect of the fingers. J Plast Reconstr Aesthet Surg 2007;60(7):710–9. [22] Azizeddin A, Choong PFM, Grinsell D. Reconstructive options for large back free flap donor sites. ANZ J Surg 2018;88(10):1066–70. [23] Chen H, Jiang C, Xu Y, Sun Y. Toe-to-finger combined with free flap transfer for primary one-stage post-traumatic reconstruction of the complex fingerless hand. J Plast Reconstr Aesthet Surg 2017;70(12):1708–14. [24] Wei FC, Al Deek NF, Lin YT, Hsu CC, Lin CH. Metacarpal-like hand: classification and treatment guidelines for microsurgical reconstruction with toe transplantation. Plast Reconstr Surg 2018;141(1):128–35.
Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Acknowledgement None. Funding sources None declared. References [1] Zhang J, Huang J, Pan J, et al. Vascular crisis after multiple tissue transplantation for thumb and other finger reconstruction by toe-to-hand transfer. Chin J Repar Reconst Surg 2017;31(3):323–6. [2] Yang J, Wang T, Yu C, Gu Y, Jia X. Reconstruction of large area defect of the nail bed by cross finger fascial flap combined with split-thickness toe nail bed graft: a new surgical method. Medicine 2017;96(6):e6048. [3] Roger de Oña I, Garcia Villanueva A, Studer de Oya A. An alternative thumb reconstruction by double microsurgical transfer from the great and second toe for a carpometacarpal amputation. J Hand Surg Am 2018;43(10):955.e1–9. [4] Kakinoki R, Hashimoto K, Tanaka H, Akagi M. Suspension arthroplasty combined with ligament reconstruction of the thumb carpometacarpal joint to salvage two failed arthroplasties: a case report. J Orthop Case Rep 2017;7(1):50–3. [5] Feng SM, Sun QQ, Cheng J, Wang AG. A novel approach for reconstruction of finger neurocutaneous defect: a sensory reverse dorsal digital artery flap from the neighboring digit. Orthop Surg 2017;9(4):372–9. [6] Lin YT, Loh CYY, Lien SH, Lin CH, Wei FC. Simultaneous Stiles-Bunnell tendon transfer enhances intrinsic function of the second toe transplantations. Plast Reconstr Surg 2017;140(6):1229–34. [7] Calafat V, Strugarek C, Montoya-Faivre D, Dap F, Dautel G. Partial medial second toe pulp free flap and dermal substitute with skin graft for salvage reconstruction of a complete skin envelope degloving of the small finger. Ann Chir Plast Esthet 2018;63(4):353–7. [8] Tsai TM, D'Agostino L, Fang YS, Tien H. Compound flap from the great toe and vascularized joints from the second toe for posttraumatic thumb reconstruction at
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Contents lists available at ScienceDirect
Medical Hypotheses journal homepage: www.elsevier.com/locate/mehy
Clinical effect of thumb finger reconstruction using dorsal foot flap transplant for treating thumb defects Z. Xuefeng1, G. Jian1, D. Jiayue, Z. Chuchen, W. Shenglin, Y. Xiao'en
T
⁎
Department of Plastic Surgery, Lishui People’s Hospital, Lishui, Zhejiang Province, China
A R T I C LE I N FO
A B S T R A C T
Keywords: Dorsal foot flap Thumb finger reconstruction with toe transplant Thumb finger defect Clinical effect
It was found that conventional toe graft alone could not meet the patients' needs for wound repair, so we hypothesized that it would be more effective to treat thumb and finger defect by toe graft with dorsalis foot flap. This prospective study was conducted in 104 thumb defect patients to investigate the clinical effect of thumb reconstruction using toe graft with dorsal foot flap for the treatment of thumb defects. These patients were randomly divided into the dorsal foot group and the control group by randomized double-blind method, with 52 patients in each group. The second toe was used for thumb reconstruction transplant in both the groups. After thumb reconstruction, the abdominal pedicled flap was used to repair the surgical wound in the control group whereas the dorsal foot flap was used to repair the surgical wound in the dorsal foot group. Three months after surgery, the efficacy of surgical treatment, evaluation of two-point discrimination, postoperative complications, function of reconstructed thumb, operation time, and hospitalization time were recorded and compared between the two groups. MHOQ questionnaire was used to evaluate and compare the patients' satisfaction with finger reconstruction in both the groups. The surgical therapeutic effect, the function of the reconstructed thumb, and satisfaction with finger reconstruction were significantly higher in the dorsal foot group compared to the control group (all p < 0.05). The postoperative two-point discrimination, postoperative complication rate, operation time, and hospitalization time of patients in the dorsal foot group were significantly lower compared to the control group (all p < 0.05). Thumb finger reconstruction using the second toe transplant with dorsal foot flap had a beneficial effect on thumb defect patients. It can effectively improve finger function and sensory recovery of patients while reducing complications.
Introduction and hypothesis
this is an ideal method for thumb reconstruction, with a high success rate [6]. However, some studies have also suggested that conventional toe transplant alone cannot meet the patients' need for wound repair in thumb injuries with large skin defects [7]. Therefore, a previous study had proposed the use of a toe transplant with a dorsal foot flap to reconstruct and repair the thumb defect in patients [8]. Some studies have indicated that since the thickness of dorsal foot flap is relatively thin and its structure is very similar to the skin of hands along with a relatively fixed vascular trend, it is conducive to the recovery of patients' hand function [9]. However, another study has shown that toe transplant with a dorsal foot flap can cause great damage to the foot and hence it is not recommended [10]. In the present study, we hypothesized that second toe transplant with a dorsal foot flap for thumb reconstruction could be effective for thumb defect patients. We carried out this treatment and compared its
As one of the main functional organs of the human body, hands are important in both labour and communication [1]. Due to work-related and other incidences, people often suffer from accidental hand injuries, which are likely to cause thumb mutilation. This not only has a serious impact on the hand aesthetics and functions but may also have a certain negative impact on the patients' psychology [2,3]. Thumb injuries often cause damage to the nail bed and the perithyroid soft tissue which makes it difficult to repair [4]. For such patients, improper treatment is very likely to cause a severe dysfunction of the hand. Therefore, timely and effective treatment is of great clinical significance for patients with thumb defect [5]. Currently, in clinical practice, second toe transplant is often used for the treatment of thumb defects and many studies have concluded that
⁎
Corresponding author at: Department of Plastic Surgery, Lishui People’s Hospital, No. 15 Dazhong Street, Liandu District, Lishui 323000, Zhejiang Province, China. E-mail address: [email protected] (Y. Xiao'en). 1 Co-first authors, contributed equally to this work. https://doi.org/10.1016/j.mehy.2019.109435 Received 31 July 2019; Received in revised form 8 October 2019; Accepted 14 October 2019 0306-9877/ © 2019 Elsevier Ltd. All rights reserved.
Medical Hypotheses 134 (2020) 109435
Z. Xuefeng, et al.
outcome with a control procedure of abdominal pedicled flap for thumb finger reconstruction following the second toe transplant.
to the arteriae digitsles plantares. The dorsal cutaneous nerve and the great saphenous vein was included when the flap was dissociated. During the transplant, the toe-metacarpal bone was fixed with Kirschner wire, the extensor flexor tendon was repaired and the proper artery of the toe and thumb was anastomosed. Subsequently, the great saphenous vein and cephalic vein of dorsal foot flap were anastomosed, the dorsal foot nerve and radial nerve were anastomosed, and finally, the wound was sutured. (3) Postoperative fixation was performed with a plaster on the hand and warmth was provided to the hand by light illumination. Anti-thrombotic, antibiotics, and anti-spastic treatment were given, and the blood flow in the hand of the patient was closely monitored. If blood flow problems were found, timely treatment was given.
Materials and methods General data This study was carried out on 104 patients with thumb defects, admitted to Lishui People’s Hospital from July 2013 to May 2017, including 58 male patients and 46 female patients. The average age of all patients was (28.3 ± 4.5) years. Patients were randomly divided into the dorsal foot and the control groups by randomized double-blind method, with 52 patients in each group. Patients in both groups received the second toe transplant for thumb reconstruction. Patients in the control group received the abdominal pedicled flap while patients in the dorsal foot group received the dorsal foot flap after thumb reconstruction to repair the surgical wound.
Observation indicators (1) Three months after surgery, the curative effect of the two groups was evaluated and compared [11]. The curative effect was divided into markedly effective (survival of all hand skin grafts after operation; normal finger function), moderately effective (skin grafts survival area ≥ 60%; normal finger function) and ineffective (skin graft necrosis after the operation; no improvements in finger dysfunction). The total efficacy of treatment = (markedly effective cases + moderately effective cases)/total cases * 100%. (2) Two-point discrimination was evaluated and compared between the two groups before and after the operation (at the pulp of the thumb). (3) The complications in the two groups were recorded and compared. The complications included arterial crisis, venous crisis, local erosion of the skin graft, infection and inflammation (including skin grafting and donor areas), and nerve injury of the hand tissue. (4) The function of the reconstructed thumb was scored and compared between the two groups. The comparison criteria were as follows: 5 points – the reconstructed thumb moved normally without effort; 3–4 points – the finger moved normally but with slight pain; 2 points – the finger moved barely with pain; and 1 point – the finger did not move. The higher the score, the better the functional recovery. (5) The operative period and duration of hospitalization of the two groups were recorded and compared. (6) The MHOQ questionnaire was used to evaluate and compare the satisfaction levels in patients of the reconstructed finger. Satisfaction was divided into very satisfied, satisfied, and unsatisfied [12]. Total satisfaction was calculated as total satisfaction = (very satisfied + satisfied)/total case * 100%. Therapeutic efficacy and postoperative complications were the main evaluation indicators while the rest were secondary observation indicators.
Inclusion and exclusion criteria Inclusion criteria: Patients meeting the diagnostic criteria for thumb defect (including complete thumb defect and partial thumb defect); patients aged 20–40 years; patients who met the surgical indications (good health conditions with no other concurrent shock; eligible for thumb reconstruction; and a thumb defect injury in accordance with grade I-V). Exclusion criteria: Patients with surgical contraindications (including patients with severe infectious diseases and allergies to anesthetics); patients with severe coagulation dysfunction (decrease or disappearance of plasma factor activity with symptoms of subcutaneous hemorrhage); patients with severe hepatorenal dysfunction (increased transaminase and urea nitrogen and serum creatinine); patients with immune system diseases; patients who refused surgery; and patients with communication or cognitive impairment. All patients and their families agreed to participate in the study and signed the informed consent document. This study has been approved by the Ethics Committee of Lishui People’s Hospital. Operative procedure Before the operation, the injured thumb was debrided thoroughly and the stump of the thumb was trimmed. (1) For the patients in the control group, finger reconstruction using second toe transplantation was combined with a traditional abdominal pedicled flap to repair the surgical wound. The first step was designing the skin flap according to the patient's injury by considering the projection line of the superficial abdominal artery as the axis. First, the skin was cut along the pedicle to expose the subcutaneous toe and then the fascia perforating branch of the abdominal wall was located. The distal end of the flap was cut retrograde from the shallow layer of the deep fascia. The deep fascia around the abdominal pedicled skin flaps was removed carefully. Subsequently, the second toe was removed. After removal, the metacarpal bone of the toe was fixed with Kirschner wire and the proper artery of the toe and thumb was anastomosed. The extensor flexor tendon was then repaired and the reconstructed vasculature of the thumb was anastomosed with the proper artery of the thumb. The nerve pedicle with an abdominal pedicled flap was anastomosed with the nerve of the thumb and the reconstructed vein was anastomosed with the subcutaneous vein of the thumb which was followed by direct suturing. (2) Patients in the dorsal foot group, on the other hand, were treated by thumb finger reconstruction using second toe transplant with a dorsal foot flap. First, the dorsal foot flap was removed according to the thumb defect of the patient. A longitudinal incision was made on the dorsal foot flap and the arteries and veins on the dorsal foot were all dissociated. The inner and outer edges of the dorsal foot flap were then cut open and the flap was dissociated along the dorsal metatarsal artery
Statistical methods SPSS19.0 software (Bizinsight Intelligence (Beijing) Information Technology Co., Ltd.) was used to analyze the experimental data. Counting data were expressed as percentages and the differences were calculated by chi-square. Measurement data were expressed by mean ± standard deviation. The measurement data between the two groups were compared using Student’s t-test for independent samples and paired Student’s t-test for comparison within the group before and after the treatment. The differences were considered significant when p < 0.05.
Results Comparison of general data There were no significant differences in gender, age, cause of thumb injury, history of diabetes mellitus, and anaemia between the two groups (all p > 0.05, Table 1). 2
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Table 1 Comparison of general data (n, %). Control group (n = 52)
Dorsal foot group (n = 52)
Gender Male Female
28 (53.85) 24 (46.15)
30 (57.69) 22 (42.31)
Age (year) ≤28 > 28
24 (46.15) 28 (53.85)
25 (48.08) 27 (51.92)
BMI (kg/m2) ≤23 > 23
25 (48.08) 27 (51.92)
24 (46.15) 28 (53.85)
Diabetes History Yes No
10 (19.23) 42 (80.77)
9 (17.31) 43 (82.69)
Anemia history Yes No
9 (17.31) 43 (82.69)
Injury causes Mechanical injury Burn Other Liver function index Total serum protein (g/L) Glutamic-pyruvic transaminase (μmol/L) Total bilirubin (μmol/L) Renal function index Creatinine (μmol/L) Serum urea (μmol/ L) Trioxypurine (μmol/ L)
χ2
p
0.156
0.623
0.038
0.844
0.039
0.844
0.064
0.800
0.070
0.791
0.060
0.971
Fig. 1. Two-point discrimination before and after the operation. *p < 0.05.
8 (15.38) 44 (84.62)
25 (48.08) 13 (25.00) 14 (26.92)
26 (50.00) 12 (23.08) 14 (26.92)
72.29 ± 2.02
72.23 ± 2.01
0.152
0.880
28.31 ± 4.46
27.82 ± 4.42
0.563
0.575
11.14 ± 2.05
11.22 ± 2.07
0.198
0.843
66.08 ± 3.14 5.56 ± 0.33
67.11 ± 3.01 5.51 ± 0.28
1.708 0.833
0.091 0.467
261.36 ± 10.33
262.29 ± 9.89
0.469
0.640
the two-point discrimination in the two groups before the operation (p = 0.936). However, the two-point discrimination decreased significantly in both groups after surgery with the two-point discrimination in dorsal foot group significantly lower compared to the control group (p < 0.001, Fig. 1). Complications in the two groups of patients In the control group, there were 4, 3, 2, 4, and 2 patients with arterial crises, venous crises, local erosion of skin graft, infection and inflammation, and nerve injury of hand tissue, respectively and the total incidence of complications was 28.85%. In the dorsal foot group, the number of patients with the arterial crisis, venous crisis, local erosion of skin graft, infection and inflammation, and nerve injury of hand tissue were 1, 1, 0, 2, and 0, respectively with a total incidence of complications of 7.69%. The incidence of complications in the dorsal foot group was significantly lower compared to the control group (p < 0.05, Table 3).
Comparison of clinical therapeutic effect Functional score of reconstructed thumbs three months after the operation The number of markedly effective, moderately effective, and ineffective therapeutic effect in the patients of the control group was 18, 19, and 15, respectively with the total efficacy at 71.15%. The number of markedly effective, moderately effective, and ineffective therapeutic effect in the patients of the dorsal foot group was 23, 25, and 4, respectively with the total efficacy at 92.31%. The total efficacy of the treatment in the dorsal foot group was significantly higher compared to the control group (p < 0.05, Table 2).
The functional score of the reconstructed thumb in the control group was (4.37 ± 0.64), 3 months after the operation while it was (5.87 ± 0.32) in the dorsal foot group. The thumb function score in the dorsal foot group was significantly higher compared to the control group, 3 months after operation (p < 0.001, Fig. 2). Comparison of the operative period and hospitalization time The operative period and hospitalization time of the control group were (49.54 ± 10.31) min and (22.14 ± 7.47) d, respectively while the operative period and hospitalization time of the dorsal foot group were (35.18 ± 9.05) min and (12.69 ± 4.58) d, respectively. Both parameters in the dorsal foot group were significantly lower compared to the control group (both p < 0.05, Table 4).
Two-point discrimination before and after the operation In the control group, the preoperative and postoperative two-point discriminations were (18.21 ± 2.56) mm and (7.43 ± 2.11) mm, respectively. In the dorsal foot group, the preoperative and postoperative two-point discriminations were (18.17 ± 2.47) mm and (5.04 ± 1.15) mm, respectively. There was no significant difference in
Table 3 Complications in the two groups of patients (n, %).
Table 2 Comparison of clinical therapeutic effect (n, %). Therapeutic effect
Markedly effective Moderately effective Ineffective Total efficacy
Control group (n = 52)
Dorsal foot group (n = 52)
18 (34.62) 19 (36.54)
23 (44.23) 25 (48.08)
15 (28.85) 37 (71.15)
4 (7.69) 48 (92.31)
χ
2
1.007 19.221
Complications
Control group (n = 52)
Dorsal foot group (n = 52)
χ2
p
Arterial crisis Venous crisis Local erosion of skin graft Infection and inflammation Nerve injury of hand tissue Total incidence of complications
4 (7.69) 3 (5.77) 2 (3.85) 4 (7.69) 2 (3.85) 15 (28.85)
1 1 0 2 0 4
1.951 1.080 2.039 0.708 2.039 7.792
0.163 0.299 0.153 0.400 0.153 0.005
p
0.316 < 0.001
3
(1.92) (1.92) (3.85) (7.69)
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Table 5 Satisfaction evaluation of reconstructed finger (n, %). Satisfaction
Control group (n = 52)
Dorsal foot group (n = 52)
χ2
p
Very satisfied Moderately satisfied Dissatisfied Total satisfaction
21 15 16 36
26 (50.00) 23 (44.23) 3 (5.77) 49 (94.23)
0.971
0.325
9.070
0.003
(40.38) (28.85) (30.77) (69.23)
the functional recovery of fingers are poor [16,17]. Another study which evaluated the effect of dorsal pedis flap in repairing finger defect showed that this method not only had a high survival rate of skin graft but also improved the blood flow and promoted the recovery of hand function [18]. Other studies suggest that dorsal pedis skin flaps can repair the defective skin of patients in addition to the damaged muscles since they have extensor digitorum tendons which effectively promote the functional recovery in patients [19]. Another study has shown that since sensory disorders could make coordinated movements difficult, the main issue of finger reconstruction in the clinic is whether patients can receive an improved finger function and sensation [20]. Subsequent studies have indicated that repairing the reconstructed thumb with dorsal foot flap could restore the two-point discrimination and improve the function of the ventral part of the toe, and could make the reconstructed thumbnail look natural [7,21]. We have reported similar observations in our study. Subsequently, we have further compared the incidence of postoperative complications between the two groups. The results showed that the incidence of postoperative complications in patients in the dorsal foot group was significantly lower compared to the control group, which suggested that the reconstruction of thumb with dorsal foot flap could effectively reduce postoperative complications in patients. We analyzed the causes of complications and found that, for example, the causes of arteriovenous crises were mainly due to tortuous vessels caused by hematoma compression and vascular pedicle compression [22]. A previous study indicated that the advantage of this surgical method is that the toe graft and the repaired skin flap share the same vascular pedicle requiring only one set of vascular system anastomosis during the operation, and thus, reduces the occurrence of a vascular crisis [23]. Combined with other complications, we found that the complications were related to the blood supply of the flap, the location of the skin graft, and the dressing and other factors, which can be studied in detail in the future. Finally, we compared the two groups of patients' satisfaction with finger reconstruction and observed that the satisfaction of patients in the dorsal foot group was significantly higher compared to the control group. This suggests that thumb defect patients still have a high degree of acceptance for finger reconstruction by toe transplant with dorsal foot flap. In conclusion, thumb finger reconstruction using second toe transplant with dorsal foot flap is effective and can effectively promote finger function and sensory recovery in thumb defects of patients. It also reduced the incidence of complications and could be used more frequently for similar thumb injuries. However, there are some limitations to this study. For example, we did not conduct a multivariate analysis of the incidence of complications. Therefore, this conclusion needs further analysis and validation. In addition, arm flap and other repair methods [24], were not evaluated for a comprehensive comparison to determine whether the second toe transplant with the dorsal foot flap is the most appropriate surgical method for thumb finger
Fig. 2. Functional score of reconstructed thumbs 3 months after the operation. *p < 0.05.
Satisfaction evaluation of reconstructed finger In the control group, 21 patients were very satisfied, 15 were moderately satisfied, and 16 were dissatisfied with the finger reconstruction with total satisfaction in 69.23%. In the dorsal foot group, 26 were very satisfied, 23 were moderately satisfied and 3 were dissatisfied with the finger reconstruction with total satisfaction of 94.23%. The satisfaction degree in the dorsal foot group was significantly higher compared to the control group (p < 0.05, Table 5).
Discussion Due to complex functions of the hand, the repaired fingers should not only have a relatively good function but also look good aesthetically. This leads to higher difficulty in the repair and reconstruction of fingers injured due to accidents [13,14]. In clinical practice, toe transplant has always been the choice of treatment to repair the thumb injury of the hand [15]. However, there is some degree of controversy about the choice of skin flaps for soft tissue repair after toe reconstruction. Therefore, in our study, we compared the effect of thumb finger reconstruction with dorsal pedicled flaps to traditional abdominal pedicled flaps. First, we compared some indicators in the two groups of patients. The results showed that the total efficacy of surgical treatment and the score of surgical reconstruction function in the dorsal foot group were significantly higher compared to the control group, while the operative period and hospitalization time were significantly lower in the dorsal foot group. Two-point discrimination decreased significantly in both the groups after surgery but was significantly lower in the dorsal foot group compared to the control group. This suggests that irrespective of whether abdominal pedicled skin flap or dorsal pedicled skin flap was used, both have some treatment efficacy in patients with thumb defect. However, toe transplant with dorsal pedicled skin flaps has a significantly higher beneficial effect. Some studies have indicated that although this method has a high survival rate, the hospital stay and recovery times are longer, and the sensory recovery of the skin flaps and Table 4 Comparison of the operative period and hospitalization time.
Operative period (min) Hospitalization time (d)
Control group (n = 52)
Dorsal foot group (n = 52)
t
p
49.54 ± 10.31 22.14 ± 7.47
35.18 ± 9.05 12.69 ± 4.58
7.548 7.777
< 0.001 < 0.001
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reconstruction. These could be a future aspect that could be explored.
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