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Thumb reconstruction with extended twisted toe flap
Thumb Reconstruction With Extended Twisted Toe Flap Martin Iglesias, MD, Patricia Butron, MD, Alfonso Serrano, MD, M~xico D.F. Twelve amputated thumbs were reconstructed with a neurovascular cutaneous flap from the great toe and an osteotendinous flap from the second toe. Both transfers were dependent on a single vascular pedicle. One of the 12 reconstructions failed. In the remaining 11, the mobility of the metacarpophalangeal joint ranged from 10~ to 50 ~ and that of the interphalangeal joint from 10 ~ to 30 ~ Opposition and key pinch were restored, and the shape and volume were similar to those of the normal thumb. Likewise, the great toe was preserved, and all patients had a normal gait. This technique preserves the epiphyses for future growth in children and maintains the aesthetic appearance of the foot, but it has the disadvantage of involving a lengthy surgical procedure with a 17% rate of major complications. (J Hand Surg 1995;20A:731-736.)
The microvascular great-toe-to-hand transfer is one option for thumb reconstruction and provides satisfactory aesthetic and functional results with good mobility of the interphalangeal joint. 1" There are, however, patients who refuse this procedure because they do not want to sacrifice their great toes for cosmetic or cultural reasons, or because the great toe is important for their work or hobbies? '6 For these patients, a second alternative for thumb reconstruction is a neurovascular-cutaneous flap (NVCF) from the great toe plus an osteotendinous flap (OTF) from the second toe. Both transfers are dependent on a single vascular pedicle and the great toe is preserved. Foucher reported this technique in 1980 to reconstruct the distal portion o f the thumb. He called this technique a "twisted-toe-flap. ''7 Kobus used it to reconstruct the thumb distal to the metacarpophaFrom the Departmentof Plastic Surgeryat Instituto Nacional de la Nutrici6n "SalvadorZubir~n,"Mrxico D.F. Received for publication Oct. 5, 1994; accepted in revised form March 7, 1995. No benefitsin any formhavebeen receivedor will be receivedfrom a commercialparty related directlyor indirectlyto the subject of this article. Reprintrequests: MartfnIglesias, MD, Caminoal Ajusco 124,casa 2, Jardines en la Montafia,C.P. 14210,MrxicoD.F.
langeal (MP) joint in six patients. 8 Tsai in 1991 reported a case in which he reconstructed a thumb at the proximal MP joint with a similar technique. 9 We reconstructed 12 thumbs using a N V C F from the great toe plus an O T F from [he second toe. Both were transferred together on a single vascular pedicle. The patients ranged in age from 6 to 45 years. The follow-up period ranged from 8 to 24 months, with an average of 12 months. E~ghr~ pauents had amputations in the proximal third o f the proximal phalanx, three at the M P joint, and one at the distal third of the metacarpal bone (Table 1).
Materials and Methods The N e u r o v a s c u l a r Cutaneous Flap
The circumference o f the normal thumb at the interphalangeal joint and the nail size are measured. With this data, the NVCF is drawn on the fibular surface of the ipsilateral great toe, including a portion of the toenail. The flap is raised by subfascial dissection, except for the distal phalanx, where the dissection is subperiosteal to avoid damage to the nail matrix. The dissected flap includes skin, nail, nail matrix, lateral plantar nerve, and some fascicles from the superficial peroneal nerve. This unit will become the cutaneous cover of the reconstructed thumb. The The Journal of Hand Surgery
731
732
Iglesias et al. / Thumb Reconstruction
Table 1. Individual Data for Reconstructed Thumbs Movement Obtained (degrees) Sex
Age (Years)
1
F
25
Proximal phalanx
2 3*
M M
19 37
Proximal phalanx Metacarpophalangeal
4* 5 6* 7* 8"~
M F M M M
6 40 18 24 27
joint Proximal phalanx Uneventful Proximal phalanx Pulp too bulky Metacarpal bone Suture dehiscence Metacarpophalangealjoint Uneventful Proximal phalanx Malrotation and
Patient
9* 10 11" 12
F M M M
24 35 45 23
Level of Amputation
Metacarpophalangeal joint Proximal phalanx Proximal phalanx Proximal phalanx
Outcomes
Metacarpophalangeal Joint
Interphalangeal Joint
0
0
0-30 0-25
0-10 0-20
0-50 0-35 0-40 0-50 0-30
0-30 0-20 0-10 0-10 0
0-10 0-25 0-30 0-25
0-20 0-15 0-10 0-15
Venous thrombosis and necrosis Uneventful Uneventful
reabsorption of the bone after corrective osteotomy Uneventful Uneventful Uneventful Pulp too bulky
*Metacarpophalangeal joint reconstruction. tMovement obtained before corrective osteotomy.
blood supply to this flap is provided by the lateral dorsal digital artery from the first dorsal metatarsal artery or the plantar digital artery from the plantar metatarsal artery. The concomitant veins plus a superficial vein are included. All of the osteotendinous structures of the great toe, plus its paratendon, periosteum, and an island of skin on the tibial surface, are left intact.
The Osteotendinous Flap The osseous structure of the reconstructed thumb comes from the skeleton and tendons of the second toe. The skin and nail are dissected through a longitudinal incision of the tibial surface of the second toe, protecting the main medial artery, which could be dorsal or plantar. This dissection is subfascial, but at the level of the distal phalanx it becomes subperiosteal to avoid damage to the nail matrix. To provide blood supply to the osteotendinous structure, the medial dorsal or plantar artery and its concomitant veins to this osteotendinous structure are protected. This vascular pedicle must remain attached to the vascular pedicle of the NVCE Both pedicles remain attached to the first dorsal or plantar metatarsal artery. After the cutaneous cover of the second toe has been dissected, it is displaced laterally to expose the bone and tendon anatomy. The bone is disarticulated
or osteotomized, and the extensor and flexor tendons are cut according to the length required. The NVCF is based on the lateral dorsal or plantar digital artery from the great toe. The OTF is based on the medial dorsal or plantar digital artery of the second toe. Both are dependent on the first dorsal or plantar metatarsal artery. The venous flow of the NVCF is maintained through a superficial vein. The venous flow of the OTF goes into the corresponding veins of its pedicle, which drain through a reverse flow of the concomitant veins of the lateral dorsal or plantar digital artery of the great toe, and these into a superficial vein (Fig. 1). Thus, only one venous anastomosis is required. We prefer a superficial vein to a deep vein (concomitant vein of the first metatarsal artery) because it is larger and easier to dissect and repair.
Forming the Thumb The distal interphalangeal joint is fused with a Kirschner wire and the NVCF is wrapped around the OTF. The lateral dorsal digital artery is dorsal to the OTF and its medial dorsal digital artery. The vascular pedicle is freed from the cutaneous flap, which permits displacement of the flap. The edges of the skin-nail flap are then sutured together on the tibial side and the unit is transferred to the hand (Fig. 2). In the hand, bone or joint stabilization, flexor and exten-
Lateral dorsal Digital artery
Medial dorsal Digital artery
;f
i
/I S!
il
V~
First dorsal .Metatarsal artery
B Figure l. (A) The neurovascular cutaneous flap from the great toe and the osteotendinous flap from the second toe, depending on the first dorsal metatarsal artery. (B) The arrows in the drawing indicate the venous flow of the osteotendinous flap into a superficial vein.
f dorsal artery
Medial dorsal Digital artery
~rficiol
First dorsa Metatorsol or
B
o.
Figure 2. (A) Flap rotation to reshape the thumb. (B) Similar drawing.
734
Iglesias et al. / Thumb Reconstruction
sor tendons suture, artery and vein anastomosis, and nerve suture are completed. Bone scans were performed on the fifth postoperative day to check viability of the OTE In the foot, the distal third of the second metatarsal bone is excised to permit wound closure and the intermetatarsal ligament repaired. The cutaneous flap of the second toe is rotated to cover the osteotendinous structure of the great toe and sutured to the remaining island flap.
Results Eleven transfers survived; one failed due to inadequate rotation of the flaps, which caused venous thrombosis. One of the surviving transfers had wound dehiscence but healed in 2 weeks. The bone
scans reported an increased activity of radioactive material in the osseous structures of the surviving transfers. Two-point discrimination was from 8 to 14 mm. The MPjoint range of motion was 10 ~ to 50 ~ and the interphalangeal joint range of motion from 10~ to 30 ~. Opposition was satisfactory, and the key pinch was between 75% and 90% of the opposite thumb. The cosmetic results were adequate compared to the opposite thumb, but two patients had bulky pulps (Figs. 3-8). In one case, malrotation required a corrective osteotomy. After this surgery, partial bony resorption resulted and required a bone graft. Irregular growth of the nail occurred early, but after 4 months became normal in appearance. The radial nail fold was similar to that achieved with wraparound techniques.
Figure 3. Patient 2. Postoperative result of the (A) thumb and (B) donor site.
Figure 4. Patient 4. Postoperative result of the (A) thumb and (B) donor site.
The Journal of Hand Surgery / Vol. 20A No. 5 September 1995
Figure 5. Patient 6. Postoperative result of (A) the thumb and (B) donor site.
Figure 6. Patient 7. Postoperative result of (A) the thumb and (B) donor site.
Figure 7. Patient 10. Postoperative result of (A) the thumb and (B) donor site.
735
736
Iglesias et al. / Thumb Reconstruction
Figure 8, Patient 12. Postoperative result of (A) the thumb and (B) donor site.
All patients had a normal gait after 2 weeks, without significant problems at the donor site. The cosmetic appearance o f the foot was satisfactory, but there was deformity in the toenails. In four patients, the great toe suffered lateral deviation that was corrected with m i n o r surgery. T w o other patients required resection o f a bulky thumb pulp.
Discussion This technique offers a thumb similar to those achieved with a wrap-around technique but is completed in one surgical stage. Another advantage is that the great toe is preserved. The active joint m o v e ment achieved by this technique is similar to that obtained with transfer of the second toe as a complete unit. The range of m o v e m e n t is enough to preserve the function of the thumb and avoid bone reabsorption. This method has two disadvantages, The first disadvantage is limited interphalangeal joint flexion. The second is the length of time it takes to perform the operation; m y average time on this surgery is 7 hours. It usually takes 1.5 to 2 hours longer than conventional g r e a t - t o e - t o - h a n d transfer.
References 1. May JW. Thumb restoration by free great toe-to-hand transfer. In: Brent B, ed. The artistry of reconstructive surgery. St. Louis: CV Mosby, 1987:813-9. 2. Buncke HJ, Valauri FA. Discussion: reconstruction of the thumb with a trimmed-tow transfer technique. Plast Reconstr Surg 1988;82:514-5. 3. Valauri FA, Buncke HJ. Thumb reconstruction great toe transfer. Clin Plast Surg 1989;16:475-89. 4. Popen NK, Norris TR, Buncke HJ Jr. Evaluation of sensibility and function with microsurgical free-tissue transfer of the great toe to the hand for thumb reconstruction. J Hand Surg 1983;8:516-30. 5. Weiss AP, Steichen JB. Reconstruction of traumatic absence of the thumb by alternative microsurgical methods of reconstruction. Hand Clin 1992;8:33-9. 6. Morrison WA, O'Brien B McC, Macleod AM. Thumb reconstruction with a free neurovascular wrap-around flap from the big toe. J Hand Surg 1980;5:575-83. 7. Foucher G, Merle M, Maneaud M, Michon J. Microsurgical free partial toe transfer in hand reconstruction: a report of 12 cases. Plast Reconstr Surg 1980;65:616-26. 8. Kobus K, Chiciak W, Stepniewski J. Rekonstrukcja kciuka za pomoca palcow stopy. Pol Przegl Chir 1985;57:652-61. 9. Tsai TM, Aziz W. Toe-to-thumb transfer: a new technique. Plast Reconstr Surg 1991;88:149-53.
The microvascular great-toe-to-hand transfer is one option for thumb reconstruction and provides satisfactory aesthetic and functional results with good mobility of the interphalangeal joint. 1" There are, however, patients who refuse this procedure because they do not want to sacrifice their great toes for cosmetic or cultural reasons, or because the great toe is important for their work or hobbies? '6 For these patients, a second alternative for thumb reconstruction is a neurovascular-cutaneous flap (NVCF) from the great toe plus an osteotendinous flap (OTF) from the second toe. Both transfers are dependent on a single vascular pedicle and the great toe is preserved. Foucher reported this technique in 1980 to reconstruct the distal portion o f the thumb. He called this technique a "twisted-toe-flap. ''7 Kobus used it to reconstruct the thumb distal to the metacarpophaFrom the Departmentof Plastic Surgeryat Instituto Nacional de la Nutrici6n "SalvadorZubir~n,"Mrxico D.F. Received for publication Oct. 5, 1994; accepted in revised form March 7, 1995. No benefitsin any formhavebeen receivedor will be receivedfrom a commercialparty related directlyor indirectlyto the subject of this article. Reprintrequests: MartfnIglesias, MD, Caminoal Ajusco 124,casa 2, Jardines en la Montafia,C.P. 14210,MrxicoD.F.
langeal (MP) joint in six patients. 8 Tsai in 1991 reported a case in which he reconstructed a thumb at the proximal MP joint with a similar technique. 9 We reconstructed 12 thumbs using a N V C F from the great toe plus an O T F from [he second toe. Both were transferred together on a single vascular pedicle. The patients ranged in age from 6 to 45 years. The follow-up period ranged from 8 to 24 months, with an average of 12 months. E~ghr~ pauents had amputations in the proximal third o f the proximal phalanx, three at the M P joint, and one at the distal third of the metacarpal bone (Table 1).
Materials and Methods The N e u r o v a s c u l a r Cutaneous Flap
The circumference o f the normal thumb at the interphalangeal joint and the nail size are measured. With this data, the NVCF is drawn on the fibular surface of the ipsilateral great toe, including a portion of the toenail. The flap is raised by subfascial dissection, except for the distal phalanx, where the dissection is subperiosteal to avoid damage to the nail matrix. The dissected flap includes skin, nail, nail matrix, lateral plantar nerve, and some fascicles from the superficial peroneal nerve. This unit will become the cutaneous cover of the reconstructed thumb. The The Journal of Hand Surgery
731
732
Iglesias et al. / Thumb Reconstruction
Table 1. Individual Data for Reconstructed Thumbs Movement Obtained (degrees) Sex
Age (Years)
1
F
25
Proximal phalanx
2 3*
M M
19 37
Proximal phalanx Metacarpophalangeal
4* 5 6* 7* 8"~
M F M M M
6 40 18 24 27
joint Proximal phalanx Uneventful Proximal phalanx Pulp too bulky Metacarpal bone Suture dehiscence Metacarpophalangealjoint Uneventful Proximal phalanx Malrotation and
Patient
9* 10 11" 12
F M M M
24 35 45 23
Level of Amputation
Metacarpophalangeal joint Proximal phalanx Proximal phalanx Proximal phalanx
Outcomes
Metacarpophalangeal Joint
Interphalangeal Joint
0
0
0-30 0-25
0-10 0-20
0-50 0-35 0-40 0-50 0-30
0-30 0-20 0-10 0-10 0
0-10 0-25 0-30 0-25
0-20 0-15 0-10 0-15
Venous thrombosis and necrosis Uneventful Uneventful
reabsorption of the bone after corrective osteotomy Uneventful Uneventful Uneventful Pulp too bulky
*Metacarpophalangeal joint reconstruction. tMovement obtained before corrective osteotomy.
blood supply to this flap is provided by the lateral dorsal digital artery from the first dorsal metatarsal artery or the plantar digital artery from the plantar metatarsal artery. The concomitant veins plus a superficial vein are included. All of the osteotendinous structures of the great toe, plus its paratendon, periosteum, and an island of skin on the tibial surface, are left intact.
The Osteotendinous Flap The osseous structure of the reconstructed thumb comes from the skeleton and tendons of the second toe. The skin and nail are dissected through a longitudinal incision of the tibial surface of the second toe, protecting the main medial artery, which could be dorsal or plantar. This dissection is subfascial, but at the level of the distal phalanx it becomes subperiosteal to avoid damage to the nail matrix. To provide blood supply to the osteotendinous structure, the medial dorsal or plantar artery and its concomitant veins to this osteotendinous structure are protected. This vascular pedicle must remain attached to the vascular pedicle of the NVCE Both pedicles remain attached to the first dorsal or plantar metatarsal artery. After the cutaneous cover of the second toe has been dissected, it is displaced laterally to expose the bone and tendon anatomy. The bone is disarticulated
or osteotomized, and the extensor and flexor tendons are cut according to the length required. The NVCF is based on the lateral dorsal or plantar digital artery from the great toe. The OTF is based on the medial dorsal or plantar digital artery of the second toe. Both are dependent on the first dorsal or plantar metatarsal artery. The venous flow of the NVCF is maintained through a superficial vein. The venous flow of the OTF goes into the corresponding veins of its pedicle, which drain through a reverse flow of the concomitant veins of the lateral dorsal or plantar digital artery of the great toe, and these into a superficial vein (Fig. 1). Thus, only one venous anastomosis is required. We prefer a superficial vein to a deep vein (concomitant vein of the first metatarsal artery) because it is larger and easier to dissect and repair.
Forming the Thumb The distal interphalangeal joint is fused with a Kirschner wire and the NVCF is wrapped around the OTF. The lateral dorsal digital artery is dorsal to the OTF and its medial dorsal digital artery. The vascular pedicle is freed from the cutaneous flap, which permits displacement of the flap. The edges of the skin-nail flap are then sutured together on the tibial side and the unit is transferred to the hand (Fig. 2). In the hand, bone or joint stabilization, flexor and exten-
Lateral dorsal Digital artery
Medial dorsal Digital artery
;f
i
/I S!
il
V~
First dorsal .Metatarsal artery
B Figure l. (A) The neurovascular cutaneous flap from the great toe and the osteotendinous flap from the second toe, depending on the first dorsal metatarsal artery. (B) The arrows in the drawing indicate the venous flow of the osteotendinous flap into a superficial vein.
f dorsal artery
Medial dorsal Digital artery
~rficiol
First dorsa Metatorsol or
B
o.
Figure 2. (A) Flap rotation to reshape the thumb. (B) Similar drawing.
734
Iglesias et al. / Thumb Reconstruction
sor tendons suture, artery and vein anastomosis, and nerve suture are completed. Bone scans were performed on the fifth postoperative day to check viability of the OTE In the foot, the distal third of the second metatarsal bone is excised to permit wound closure and the intermetatarsal ligament repaired. The cutaneous flap of the second toe is rotated to cover the osteotendinous structure of the great toe and sutured to the remaining island flap.
Results Eleven transfers survived; one failed due to inadequate rotation of the flaps, which caused venous thrombosis. One of the surviving transfers had wound dehiscence but healed in 2 weeks. The bone
scans reported an increased activity of radioactive material in the osseous structures of the surviving transfers. Two-point discrimination was from 8 to 14 mm. The MPjoint range of motion was 10 ~ to 50 ~ and the interphalangeal joint range of motion from 10~ to 30 ~. Opposition was satisfactory, and the key pinch was between 75% and 90% of the opposite thumb. The cosmetic results were adequate compared to the opposite thumb, but two patients had bulky pulps (Figs. 3-8). In one case, malrotation required a corrective osteotomy. After this surgery, partial bony resorption resulted and required a bone graft. Irregular growth of the nail occurred early, but after 4 months became normal in appearance. The radial nail fold was similar to that achieved with wraparound techniques.
Figure 3. Patient 2. Postoperative result of the (A) thumb and (B) donor site.
Figure 4. Patient 4. Postoperative result of the (A) thumb and (B) donor site.
The Journal of Hand Surgery / Vol. 20A No. 5 September 1995
Figure 5. Patient 6. Postoperative result of (A) the thumb and (B) donor site.
Figure 6. Patient 7. Postoperative result of (A) the thumb and (B) donor site.
Figure 7. Patient 10. Postoperative result of (A) the thumb and (B) donor site.
735
736
Iglesias et al. / Thumb Reconstruction
Figure 8, Patient 12. Postoperative result of (A) the thumb and (B) donor site.
All patients had a normal gait after 2 weeks, without significant problems at the donor site. The cosmetic appearance o f the foot was satisfactory, but there was deformity in the toenails. In four patients, the great toe suffered lateral deviation that was corrected with m i n o r surgery. T w o other patients required resection o f a bulky thumb pulp.
Discussion This technique offers a thumb similar to those achieved with a wrap-around technique but is completed in one surgical stage. Another advantage is that the great toe is preserved. The active joint m o v e ment achieved by this technique is similar to that obtained with transfer of the second toe as a complete unit. The range of m o v e m e n t is enough to preserve the function of the thumb and avoid bone reabsorption. This method has two disadvantages, The first disadvantage is limited interphalangeal joint flexion. The second is the length of time it takes to perform the operation; m y average time on this surgery is 7 hours. It usually takes 1.5 to 2 hours longer than conventional g r e a t - t o e - t o - h a n d transfer.
References 1. May JW. Thumb restoration by free great toe-to-hand transfer. In: Brent B, ed. The artistry of reconstructive surgery. St. Louis: CV Mosby, 1987:813-9. 2. Buncke HJ, Valauri FA. Discussion: reconstruction of the thumb with a trimmed-tow transfer technique. Plast Reconstr Surg 1988;82:514-5. 3. Valauri FA, Buncke HJ. Thumb reconstruction great toe transfer. Clin Plast Surg 1989;16:475-89. 4. Popen NK, Norris TR, Buncke HJ Jr. Evaluation of sensibility and function with microsurgical free-tissue transfer of the great toe to the hand for thumb reconstruction. J Hand Surg 1983;8:516-30. 5. Weiss AP, Steichen JB. Reconstruction of traumatic absence of the thumb by alternative microsurgical methods of reconstruction. Hand Clin 1992;8:33-9. 6. Morrison WA, O'Brien B McC, Macleod AM. Thumb reconstruction with a free neurovascular wrap-around flap from the big toe. J Hand Surg 1980;5:575-83. 7. Foucher G, Merle M, Maneaud M, Michon J. Microsurgical free partial toe transfer in hand reconstruction: a report of 12 cases. Plast Reconstr Surg 1980;65:616-26. 8. Kobus K, Chiciak W, Stepniewski J. Rekonstrukcja kciuka za pomoca palcow stopy. Pol Przegl Chir 1985;57:652-61. 9. Tsai TM, Aziz W. Toe-to-thumb transfer: a new technique. Plast Reconstr Surg 1991;88:149-53.