Thumb reconstruction using wrap-around flap from the big toe, dorsalis pedis flap and iliac crest bone graft: a report of 5 cases

Abstract

Objective To explore the surgical techniques and clinical outcomes of combined transfer of big toe wrap-around flap and dorsalis pedis flap with iliac bone graft for reconstruction of the whole thumb. Methods Five patients with complete thumb defect underwent combined transfer of the wrap-around flap from the big toe and the dorsalis pedis flap. The bone defect was repaired by non-vascularized iliac bone graft. Results Primary wound healing was achieved in all the patients. The reconstructed thumbs all survived uneventfully. Partial necrosis of the skin graft at the big toe donor site occurred in one case which was healed after dressing change. X-ray examination 8 to 12 weeks after the surgery revealed bone union between the grafted bone and the remaining thumb phalanx, when the internal fixation was removed. The patients were follow-up for 8 to 38 months. The appearance of the reconstructed thumb was comparable to a normal one. The thumbs had good perfusion and proper nail growth. Sensory recovery reached S2 to S3 on the dorsum of the thumb and S2 to S4 on the pulp. No motion was observed in 2 cases with metacarpophalangeal joint fusion. Opposition with the fingers and palmar opposition could be accomplished in all 5 cases. Nonunion and resorption of the grafted bone did not occur. According to the functional evaluation criteria for thumb and finger reconstruction issued by the Chinese Medical Association, the results were excellent in 4 cases and good in 1 case. Skin graft at the donor sites healed well without ulceration or scar contracture. Walking was not impaired. Linear scar occurred in the iliac donor sites without discomfort. The patients were satisfied with the results. Conclusion Combined transfer of big toe wrap-around flap and dorsalis pedis flap with iliac bone graft is an ideal procedure for reconstruction of the whole thumb. It restores the proper appearance of the thumb without sacrificing any toes. Key words: Thumbs; Surgical flaps; Defects; Grafted bone