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Immediate free vascularized joint transfer from second toe to index finger proximal interphalangeal joint: A case report
Immediate Free Vascularized Joint Transfer from Second Toe to Index Finger Proximal Interphalangeal Joint: A Case Report T. M. TSAI, R. SINGER, E. ELLIOTT and H. KLEIN From Louisville, Kentucky, Stanford and Sacramento, California. The results of treatment of severe injuries to the proximal interphalangeal joint are unsatisfactory. The methods of joint reconstruction are discussed, including fusion,'tmplant arthroplasty, perichondriai 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. The results of treatment of the proximal interphalangeal joint are unsatisfactory. Prior to the development of microsurgical :techniques fusion, amputation, and prosthetic replacement were the treatment modalities available. Each of these alternatives has its own limitations. While prosthetic joint technology has continued to improve (Swanson, 1970) these devices remain unsuitable in the presence of open epiphyses, soft tissue loss, or bony comminution. Fusion of the proximal interphalangeal joint is often unacceptable because of age, occupation or cosmetic result (Flatt, 1973). The results of free non-vascularized total joint transfer have been shown to be unacceptable because of degenerative changes in the articular cartilage and resultant epiphyseal closure (Graham, 1954; Erd61yi, 1963 a and b; Entin, 1962). On the other hand, after free total joint transfer using microsurgical anastomosis of the vascular pedicle, epiphyseal growth and viability of articular cartilage have been demonstrated, (Buncke, 1967; Campbell, 1975; Eades, 1966; Goldberg, 1980; Horwitz, 1963; Tsai, 1982a; Tsai, 1982b). The following case exemplifies the use of free vascularized joint transfer as an immediate treatment possibility. Case Report A twenty-four year old male machine operator sustained a crush injury to his dominant left index finger resulting in loss of dorsal skin and extensor tendon mechanism, and comminuted fractures of the distal one-half of the proximal phalanx and proximal one-third of the middle phalanx. The palmar skin, flexor tendons, ulnar lateral band and neurovascular bundles were intact (Figures 1 & 2). Received for publication February. 1984. Tsu-Min Tsai, M.D., 250 E. LibertyStreet, Louisville, Kentucky40202, U.S.A. VOL. 10-B No. ! FEBRUARY 1985
Fig. 1
Severe crush injury to the dorsum o f the index over the proximal interphalangeal joint with loss o f skin, extensor tendon mechanism and comminuted fracture of the joint.
The patient was immediately taken to the operating room where all devitalized structures were excised using axillary block and spinal anaesthesia. A 1.5 cm by 4.5 cm skin island was marked over the second toe proximal interphalangeal joint. (Pre-operative radiographs of the foot were taken to determine the most. appropriate toe for transfer.) A dorsal 85
TSU-MIN TSAI, R. SINGER, E. ELLIOTT AND H. KLEIN
Fig. 2
Fig. 3
86
X-ray showing bony loss both proximally and distally to th~ joint.
A skin island 1.5 x 4.5 cm was designed over the left second toe proximal interphalangeal joint.
Fig. 4
Isolation of composite free tissue with its neurovascular bundle.
Fig. 5
lnterposilional bone pegs fashioned from tibial grafts to attain bone approximation of the composite transfer. TIlE JOURNALOF IIAND SURGERY
FREE TOE JOINT TRANSFER
longitudinal incision between the first and second rays was used to explore the dorsalis pedis and first dorsal metatarsal arteries and the venous arch. The arterial dissection continued to the common digital artery (Figure 3). Once the neurovascular pedicle had been dissected, that portion of the second toe including dorsal skin, two dorsal veins, extensor tendons, and the appropriate length of proximal and middle phalanges was removed (Figure 4). The toe was then placed into the defect of the index finger. Bone fixation was achieved with intermedullary bone pegs fashioned from tibial grafts and interosseous wiring (Figure 5). Vascular anastomosis was performed in the following manner: An interposition vein graft which had been taken from the foot was interposed between the common digital artery on the ulnar side and the artery of the pedicle. The vein graft was anastomosed end-toside in a " Y " fashion. Dorsal veins were anastomosed to veins in the hand. The digital nerve was repaired. The extensor tendon mechanism was repaired in the following manner: Lateral bands from the toe ~vere attached to the lateral bands of the finger. The central slip was attached distally to the terminal tendon and proximally at the metacarpophalangeal joint, thus
Fig. 7
X-ray depicting closure of donor bony defect with a fibular bone graft to maintain phalangeal length.
allowing as normal an anatomical relationship as possible. The wound was closed utilizing dorsal skin from the transplanted toe (Figure 6).
The defect at the second toe was closed using tibial bone and split thickness skin grafts (Figure 7).
Postoperative Course Active motion was begun on the first postoperative day and the patient was discharged from the hospital on the fourth postoperative day. He was allowed protected active motion and he returned to operating his machine one month after discharge from the hospital.
One year post injury the patient was noted to have 40/80 ~ motion of the proximal interphalangeal joint which necessitated volar plate release and z-plasty of the volar skin. At that time an iliac bone graft to the donor toe was done for nonunion.
Fig. 6
Skin island loosely sutured, restoring the soft tissue defect of the dorsum of the proximal interphalangeal joint.
VOL. 10-BNo. I FEBRUARY1985
Two years post injury the patient had 15/60 ~ of painless active range of motion and 15/65 ~ passive range of motion of the proximal interphalangeal joint (Figure 8). Jamar grip strength was 150 pounds on the unaffected hand and 100 pounds on the affected side while pinch was twenty pounds on the affected and nineteen pounds on the unaffected hand. The patient had no foot pain and was noted to have clinical and radiographical evidence of bone union of the second toe. 87
TSU-MIN TSAI, R. SINGER, E. ELLIOTT AND H. KLEIN
Fig. 9 Fig. 8
Follow up at two years.
Discussion
Destruction of the proximal interphalangeai joint particularly of the index finger will result in a severe functional deficit. Treatment options available include fusion, implant arthroplasty, perichondrial graft, free vascular joint transfer, or amputation. In this case primary fusion was not done because of the amount of comminution and soft tissue deficit which would have necessitated an unacceptable amount of shortening. Although stability might have been achieved, a staged fusion (i.e. the use of a silastic spacer to maintain length until soft tissue healing was achieved) was not done because of the necessity of a second operative procedure and the fact that the proximal interphalangeal joint would be fused thus leaving the patient with an inferior functional result. Primary implant arthroplasty was not done because of the comminuted bone, the soft tissue defect and the instability which occurs when this technique is used in a border digit. It also appeared obvious that perichondrial arthroplasty could not be used because of lack of bony architecture and the uncertainty of long term function. (Personal communication Kutz, 1983). Amputation was not considered. 88
X-rays at two years intercalated segment.
follow up.
Lateral
view shows
Finally, our results with elective free vascularized joint transfer approach those for Swanson implant arthroplasty when used for trauma (Tsai, 1982a). One may argue that immediate transfer was not indicated because of the possibility of increased morbidity to the patient. The wound was not grossly contaminated nor did the patient sustain any associated injuries. The total operating time was five hours. Nonunion of the second toe and flexion contracture necessitated additional procedures. This boutonni6re-like deformity may have occurred in part as a result of an inappropriately long proximal phalangeal length allowing the transferred joint to act as an "intercalated segment." (Landsmeer, 1961) (Figure 9). Free vascularized total joint transfer has proved to be a suitable method for the reconstruction of the injured joint. It provides autogenous bone, articular cartilage, tendon and skin. The joint is stable and ranges of motion equal to those for implant arthroplasty for trauma have resulted with the potential for longevity. Immediate vascularized total joint replacement poses no additional problems provided there is good patient selection and meticulous surgical principles are adhered to. The availability of two operating teams as well as an operating room staff familiar with the procedure is also of great importance. TIlE JOURNAL OF [lAND SURGERY
FREE TOE JOINT TRANSFER References BUNCKE, H. J., Jr., DANILLER, A. 1., SCtlULZ, W. P. and CHASE, R. A. (1967). The Fate of Autogenous Whole Joints Transplanted by Microvascular Anastomoses. Plastic and Reconstructive Surgery 39: 333-341. CAMPBELL, C. J. (1972) Homotransplantation of a Half or Whole Joint. Clinical Orthopaedics and Related Research 87: 146-155. EADES, J. W. and PEACOCK, E. E. (1966). Autogcnous Transplantation of an Interphalangeal Joint and Proximal Phalangeal Epiphysis: Case Report and Ten-Year Follow-up. The Journal of Bone and Joint Surgery 48A: 775-778. ENTIN, M. A., ALGER, J. R. and BAIRD, R. M. (1962). Experimental and Clinical Transplantation of Autogenous Whole Joints, The Journal of Bone and Joint Surgery 44A: 1518-1536. ERDI~LYI, R. (1963). Experimental Autotransplantation of Small Joints. Plastic and Reconstructive Surgery 31: 129-139. ERDI~LYI, R. (1963). Reconstruction of Ankylosed Finger Joints by Means of Transplantation of Joints from the Foot. Plastic and Reconstruhtive Surgery 31: 140-150. FLATT, A. E. (1973). Studies in Finger Joint Replacement. A Review of the Present Position. Archives of Surgery 107: 437-443.
VOI.. 10-B No. 1 FEBRUARY 1985
GOLDBERG, V. M., PORTER, B. P., LANCE, E. M. (1980). Transplantation of the Canine Knee Joint on a Vascular Pedicle. A Preliminary Study. The Journal of Bone and Joint Surgery 62A: 414-424. GRAIIAM, W. C. (19.54). Transplantation of Joints to Replace Diseased or Damaged Articulations in the tland. The American Journal of Surgery 88: 136-141. HURWITZ, P. J. (1979). Experimental Transplantation of Small Joints by Microvascular Anastomoses. Plastic and Reconstructive Surgery 64: 221-231. LANDSMEER, J. M. F. (1961). Studies in the Anatomy of Articulation I. The equilibrium of the "intercalated" bone. Acta Morphologica NcerlandoScandinavica 3: 287-303. SWANSON, A. B. (1970). Arthroplasty in Traumatic Arthritis of the Joints of the Hand. Orthopedic Clinics of North America I: 285-298. TSAI, T. M., JUPITER, J. B., KUTZ, J. E., KLEINERT, |1. E. (1982) (a) Vascularized autogenous ',,,hole joint transfer in the hand--A clinical study, The Journal of Hand Surgery 7: 335-342. TSAI, T. M., OGDEN, L., JAEGER, S. H. and OKUBO, K. (1982) (b) Experimental vaseularized total joint autografts--A primate study, The Journal of Hand Surgery 7: 140-146.
89
Fig. 1
Severe crush injury to the dorsum o f the index over the proximal interphalangeal joint with loss o f skin, extensor tendon mechanism and comminuted fracture of the joint.
The patient was immediately taken to the operating room where all devitalized structures were excised using axillary block and spinal anaesthesia. A 1.5 cm by 4.5 cm skin island was marked over the second toe proximal interphalangeal joint. (Pre-operative radiographs of the foot were taken to determine the most. appropriate toe for transfer.) A dorsal 85
TSU-MIN TSAI, R. SINGER, E. ELLIOTT AND H. KLEIN
Fig. 2
Fig. 3
86
X-ray showing bony loss both proximally and distally to th~ joint.
A skin island 1.5 x 4.5 cm was designed over the left second toe proximal interphalangeal joint.
Fig. 4
Isolation of composite free tissue with its neurovascular bundle.
Fig. 5
lnterposilional bone pegs fashioned from tibial grafts to attain bone approximation of the composite transfer. TIlE JOURNALOF IIAND SURGERY
FREE TOE JOINT TRANSFER
longitudinal incision between the first and second rays was used to explore the dorsalis pedis and first dorsal metatarsal arteries and the venous arch. The arterial dissection continued to the common digital artery (Figure 3). Once the neurovascular pedicle had been dissected, that portion of the second toe including dorsal skin, two dorsal veins, extensor tendons, and the appropriate length of proximal and middle phalanges was removed (Figure 4). The toe was then placed into the defect of the index finger. Bone fixation was achieved with intermedullary bone pegs fashioned from tibial grafts and interosseous wiring (Figure 5). Vascular anastomosis was performed in the following manner: An interposition vein graft which had been taken from the foot was interposed between the common digital artery on the ulnar side and the artery of the pedicle. The vein graft was anastomosed end-toside in a " Y " fashion. Dorsal veins were anastomosed to veins in the hand. The digital nerve was repaired. The extensor tendon mechanism was repaired in the following manner: Lateral bands from the toe ~vere attached to the lateral bands of the finger. The central slip was attached distally to the terminal tendon and proximally at the metacarpophalangeal joint, thus
Fig. 7
X-ray depicting closure of donor bony defect with a fibular bone graft to maintain phalangeal length.
allowing as normal an anatomical relationship as possible. The wound was closed utilizing dorsal skin from the transplanted toe (Figure 6).
The defect at the second toe was closed using tibial bone and split thickness skin grafts (Figure 7).
Postoperative Course Active motion was begun on the first postoperative day and the patient was discharged from the hospital on the fourth postoperative day. He was allowed protected active motion and he returned to operating his machine one month after discharge from the hospital.
One year post injury the patient was noted to have 40/80 ~ motion of the proximal interphalangeal joint which necessitated volar plate release and z-plasty of the volar skin. At that time an iliac bone graft to the donor toe was done for nonunion.
Fig. 6
Skin island loosely sutured, restoring the soft tissue defect of the dorsum of the proximal interphalangeal joint.
VOL. 10-BNo. I FEBRUARY1985
Two years post injury the patient had 15/60 ~ of painless active range of motion and 15/65 ~ passive range of motion of the proximal interphalangeal joint (Figure 8). Jamar grip strength was 150 pounds on the unaffected hand and 100 pounds on the affected side while pinch was twenty pounds on the affected and nineteen pounds on the unaffected hand. The patient had no foot pain and was noted to have clinical and radiographical evidence of bone union of the second toe. 87
TSU-MIN TSAI, R. SINGER, E. ELLIOTT AND H. KLEIN
Fig. 9 Fig. 8
Follow up at two years.
Discussion
Destruction of the proximal interphalangeai joint particularly of the index finger will result in a severe functional deficit. Treatment options available include fusion, implant arthroplasty, perichondrial graft, free vascular joint transfer, or amputation. In this case primary fusion was not done because of the amount of comminution and soft tissue deficit which would have necessitated an unacceptable amount of shortening. Although stability might have been achieved, a staged fusion (i.e. the use of a silastic spacer to maintain length until soft tissue healing was achieved) was not done because of the necessity of a second operative procedure and the fact that the proximal interphalangeal joint would be fused thus leaving the patient with an inferior functional result. Primary implant arthroplasty was not done because of the comminuted bone, the soft tissue defect and the instability which occurs when this technique is used in a border digit. It also appeared obvious that perichondrial arthroplasty could not be used because of lack of bony architecture and the uncertainty of long term function. (Personal communication Kutz, 1983). Amputation was not considered. 88
X-rays at two years intercalated segment.
follow up.
Lateral
view shows
Finally, our results with elective free vascularized joint transfer approach those for Swanson implant arthroplasty when used for trauma (Tsai, 1982a). One may argue that immediate transfer was not indicated because of the possibility of increased morbidity to the patient. The wound was not grossly contaminated nor did the patient sustain any associated injuries. The total operating time was five hours. Nonunion of the second toe and flexion contracture necessitated additional procedures. This boutonni6re-like deformity may have occurred in part as a result of an inappropriately long proximal phalangeal length allowing the transferred joint to act as an "intercalated segment." (Landsmeer, 1961) (Figure 9). Free vascularized total joint transfer has proved to be a suitable method for the reconstruction of the injured joint. It provides autogenous bone, articular cartilage, tendon and skin. The joint is stable and ranges of motion equal to those for implant arthroplasty for trauma have resulted with the potential for longevity. Immediate vascularized total joint replacement poses no additional problems provided there is good patient selection and meticulous surgical principles are adhered to. The availability of two operating teams as well as an operating room staff familiar with the procedure is also of great importance. TIlE JOURNAL OF [lAND SURGERY
FREE TOE JOINT TRANSFER References BUNCKE, H. J., Jr., DANILLER, A. 1., SCtlULZ, W. P. and CHASE, R. A. (1967). The Fate of Autogenous Whole Joints Transplanted by Microvascular Anastomoses. Plastic and Reconstructive Surgery 39: 333-341. CAMPBELL, C. J. (1972) Homotransplantation of a Half or Whole Joint. Clinical Orthopaedics and Related Research 87: 146-155. EADES, J. W. and PEACOCK, E. E. (1966). Autogcnous Transplantation of an Interphalangeal Joint and Proximal Phalangeal Epiphysis: Case Report and Ten-Year Follow-up. The Journal of Bone and Joint Surgery 48A: 775-778. ENTIN, M. A., ALGER, J. R. and BAIRD, R. M. (1962). Experimental and Clinical Transplantation of Autogenous Whole Joints, The Journal of Bone and Joint Surgery 44A: 1518-1536. ERDI~LYI, R. (1963). Experimental Autotransplantation of Small Joints. Plastic and Reconstructive Surgery 31: 129-139. ERDI~LYI, R. (1963). Reconstruction of Ankylosed Finger Joints by Means of Transplantation of Joints from the Foot. Plastic and Reconstruhtive Surgery 31: 140-150. FLATT, A. E. (1973). Studies in Finger Joint Replacement. A Review of the Present Position. Archives of Surgery 107: 437-443.
VOI.. 10-B No. 1 FEBRUARY 1985
GOLDBERG, V. M., PORTER, B. P., LANCE, E. M. (1980). Transplantation of the Canine Knee Joint on a Vascular Pedicle. A Preliminary Study. The Journal of Bone and Joint Surgery 62A: 414-424. GRAIIAM, W. C. (19.54). Transplantation of Joints to Replace Diseased or Damaged Articulations in the tland. The American Journal of Surgery 88: 136-141. HURWITZ, P. J. (1979). Experimental Transplantation of Small Joints by Microvascular Anastomoses. Plastic and Reconstructive Surgery 64: 221-231. LANDSMEER, J. M. F. (1961). Studies in the Anatomy of Articulation I. The equilibrium of the "intercalated" bone. Acta Morphologica NcerlandoScandinavica 3: 287-303. SWANSON, A. B. (1970). Arthroplasty in Traumatic Arthritis of the Joints of the Hand. Orthopedic Clinics of North America I: 285-298. TSAI, T. M., JUPITER, J. B., KUTZ, J. E., KLEINERT, |1. E. (1982) (a) Vascularized autogenous ',,,hole joint transfer in the hand--A clinical study, The Journal of Hand Surgery 7: 335-342. TSAI, T. M., OGDEN, L., JAEGER, S. H. and OKUBO, K. (1982) (b) Experimental vaseularized total joint autografts--A primate study, The Journal of Hand Surgery 7: 140-146.
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