Donor Foot Research Articles

Preliminary application of antibiotic bone cement directly inducing skin regeneration technology in repairing of wound in lateral toe flap donor area

To investigate the feasibility and effectiveness of antibiotic bone cement directly inducing skin regeneration technology in the repairing of wound in the lateral toe flap donor area. Between June 2020 and February 2023, antibiotic bone cement directly inducing skin regeneration technology was used to repair lateral toe flap donor area in 10 patients with a total of 11 wounds, including 7 males and 3 females. The patients' age ranged from 21 to 63 years, with an average of 40.6 years. There were 3 cases of the distal segment of the thumb, 2 cases of the distal segment of the index finger, 1 case of the middle segment of the index and middle fingers, 1 case of the distal segment of the middle finger, and 3 cases of the distal segment of the ring finger. The size of the skin defect of the hand ranged from 2.4 cm×1.8 cm to 4.3 cm×3.4 cm. The disease duration ranged from 1 to 15 days, with an average of 6.9 days. The flap donor sites were located at fibular side of the great toe in 5 sites, tibial side of the second toe in 5 sites, and tibial side of the third toe in 1 site. The skin flap donor site wounds could not be directly sutured, with 2 cases having exposed tendons, all of which were covered with antibiotic bone cement. All patients were followed up 6 months to 2 years, with an average of 14.7 months. All the 11 flaps survived and had good appearance. The wound healing time was 40-72 days, with an average of 51.7 days. There was no hypertrophic scar in the donor site, which was similar to the color of the surrounding normal skin; the appearance of the foot was good, and wearing shoes and walking of the donor foot were not affected. It is a feasible method to repair the wound in the lateral foot flap donor area with the antibiotic bone cement directly inducing skin regeneration technology. The wound heals spontaneously, the operation is simple, and there is no second donor site injury.

Foot Plantar Pressure Profile Alteration after Microsurgical Great Toe-to-thumb Transfer.

Microsurgical great toe-to-thumb transfer (mGTT) is a widely used procedure when immediate replantation of thumb is not feasible. The aim of this study was to investigate the alteration of plantar pressure profile of the donor foot after mGTT. Twenty patients receiving microsurgical great toe-to-hand transfer between 1985 to 2014, and 16 healthy subjects were recruited. Group 1 consisted of 20 feet receiving mGTT, whereas group 2 consisted of 32 normal feet as control. The flap design in this study was to preserve 1 cm of the proximal phalanx to maintain the attachment of the plantar aponeurosis and intrinsic muscles. The Taiwan Chinese version of the Foot Function Index was used for patient-reported outcome measurement. A novel Emed-X system was used for dynamic plantar pressure measurement. A total of four parameters were collected, including peak pressure, contact area, contact time, and pressure-time integral. In group 1, the peak pressure redistributed under the first metatarsal bone and was significantly higher than group 2 (P < 0.05). There was no significant change of the contact area between the midfoot region of group 1 and group 2 (P > 0.05). Furthermore, similar foot clearance efficiency was demonstrated in group 1 and group 2 (P > 0.05). The windlass effect of the foot will not be affected when performing mGTT with preservation of 1 cm of the proximal phalanx. Therefore, this surgical procedure is highly recommended for clinical application.

Donor Foot Morbidity Following Nonvascularized Toe Phalanx Transfer Utilizing a New Reconstruction Technique.

Nonvascularized toe phalanx transfer is an accepted surgical option for short and hypoplastic digits in congenital hand abnormalities. However, one of the criticisms of this technique is the donor site morbidity. The purpose of this study was to evaluate donor foot morbidity after nonvascularized toe phalanx transfer using a new donor site reconstruction technique. We retrospectively reviewed 116 nonvascularized toe phalanx transfers in 69 children between 2001 and 2020 in whom the donor foot was reconstructed with a new technique using iliac osteochondral bone graft with periosteum. Feet treated with an isolated donor proximal phalanx of the fourth toe were selected and morbidity was assessed both subjectively and objectively at a minimum of 2 years after surgery. Motion, stability, and alignment of the metatarsophalangeal joint were clinically evaluated. The relative length of the fourth toe to the third toe was measured on a roentgenogram. The satisfaction of the parents for overall function and appearance was evaluated using a visual analog scale. Ninety-four operated feet in 65 patients, including 43 boys and 22 girls, were included. The right foot was evaluated in 52 patients and the left foot in 42 patients. The mean age at operation was 2 years and the mean follow-up period was 7.6 years. Motion at the metatarsophalangeal joint was good at 69% with an average extension of 45 degrees and flexion of 25 degrees. Stability and alignment were good at 95% and 84%, respectively. Only 4 toes had gross instability and 4 toes with poor alignment required revision surgery. Sixty-two toes (66%) maintained proportional length and 9 toes were graded as short. Parental satisfaction was high for appearance as well as function. This newly described technique of using iliac osteochondral bone graft with periosteum to reconstruct toe phalanx donors provided satisfactory results. The function and appearance of the donor foot after a nonvascularized toe phalanx transfer was well preserved. Level IV; therapeutic.

Composite classification and algorithmic reconstruction of fingertip defects with free lateral great toe flaps

This study aimed to classify fingertip defects according to dimensions and composite content, and present algorithmic reconstruction results with free lateral great-toe flaps. A total of 33 patients who underwent reconstruction for full-thickness defects of fingertips with free lateral great-toe flaps were retrospectively reviewed. Patients were divided into four groups by the algorithm according to the dimension and content of defects. Functional disabilities of the upper extremities, limitations of donor feet, finger cosmetics, sensory recovery, and pinch power were evaluated using the disabilities of the arm, shoulder and hand, foot function index, 5-point Likert satisfaction scales, Semmes-Weinstein monofilament and static 2-point discrimination tests, and pulp pinch-strength test, respectively. The standardized distribution of patients according to dimensions and content of defects was achieved. When the composite content of defects increase such as group 4, complex surgical skills are required, duration of surgery is extended, return to work is delayed, and donor-site complications are increased. Functional limitations of the hands improved normally after reconstruction (p<0.00). Sensory recovery of flaps was normal and test scores were strongly correlated (p=0.78). All patients and observers were satisfied with finger's cosmetics. Our classification and reconstruction algorithm is simple and easy to apply for all fingertip defects without complicated reference points, and it provides information about the surgical and post-surgical periods. When the dimension and composite deformities of the defect increase through groups 1-4, more complex reconstruction, increased donor-site complications, prolonged duration of surgery, and delayed return to work are observed.

Non-vascularized toe phalanges transplantation in congenital hand malformations

According to the world literature, congenital malformations of the upper limb are found in 2.37.9 per 10 thousand live births, while anomalies in the development of the hand occur in 6595% of patients, the most common are reduction anomalies (brachydactyly, ectrodactyly, adactyly, hypoplasia). Various methods of reconstructive plastic surgery are known in the world literature, including microsurgery, compression-distraction osteosynthesis, various types of skin, tendon-muscle and bone plasty, as well as prosthetics. Non-vascularized toe phalanges transplantation is a less common method, which is effective and technically accessible in case of reduction anomalies of the hand. This study is aimed at studying the relevance of the application of the presented method based on the analysis of world literature.&#x0D; The aim of the review is the analysis of the world experience of using non-vascularized toe phalanges transplantation in case of congenital hand malformations. A search was made for literature sources in the open electronic databases PubMed and eLibrary for the last 110 years. The publications devoted to the study of the effectiveness of transplanting the phalanges of the toes into defects of the fingers in clinical practice are analyzed. This method has a number of advantages: low morbidity for the donor foot, minimal risk of resorption of the transplanted graft, restoration of the anatomy of the formed finger, preservation of blood supply and sensitivity in the formed finger, the possibility of phalanx growth while maintaining the growth zone, the functionality of the fingers. At the same time, such issues as the detailed functioning of the growth zone of the non-perfusion phalanx after its transplantation, the reasons for the continuation or cessation of growth in the short term after surgery, the resorption of displaced phalanges, and the dependence of the mobility of the reconstructed fingers on the technology of interventions are not indicated anywhere.&#x0D; Conducting further research on the role of transplantation of non-vascularized toe phalanges in the pathology of the hand in children seems to be an actual task.

Assessment of the Foot Donor Site Morbidity After Non-Vascularized Toe Phalanx Transfer to the Hand

Background. Non-vascularized is one of the available methods of reconstructive surgery for the treatment of the hand congenital anomalies. The the impact of toe phalanx transfer on the appearance and functionality of the donor site in the long term is relevant.&#x0D; Aim of the study an objective assessment of the appearance, shape and functional state of the foot in the long-term period after the toe phalanx transfer into defects of the fingers in congenital and obtained hand pathologies.&#x0D; Methods. On the basis of the Federal Scientific Center for the Rehabilitation of the Disabled named after G.A. Albrecht 40 patients were examined, who, aged from 8 months to 11 years (in the period 2013-2022), underwent 54 toe phalanx transfer to the hand. The proximal or middle phalanx of the IV and II toes were used as a graft. To assess the condition of the feet in the long term, all patients underwent clinical and radiological studies. 12 patients aged 3 to 13 years underwent computerized plantography, podometry and barodynamoplantography.&#x0D; Results. After donor feet examination in the long-term period, lots of them showed a linear shortening of the donor toes compared to the contralateral foot, which was recorded by a computer planto-podometric method for evidence. The barodinamoplantographic study did not show significant signs of a decrease in the support ability of the foot, which could be associated with non-vascularized toe phalanx transfer. When walking, there were no obvious signs of impaired motor functions of the donor foot.&#x0D; Conclusion. It was objectively confirmed that the non-vascularized toe phalanx transfer to the hand does not significantly affect the shape and statodynamic function of the foot in the long-term follow-up period, despite the shortening of the donor toes.

Clinical effects of free hallux-nail flap combined with the second toe composite tissue flap in the reconstruction of damaged thumb after electrical burns

Objective: To explore the clinical effects of free hallux-nail flap combined with the second toe composite tissue flap in the reconstruction of damaged thumb after electrical burns. Methods: A retrospective observational study was conducted. From May 2018 to April 2021, 12 male patients with thumb destructive defects caused by electrical burns who met the inclusion criteria were admitted to Zhengzhou First People's Hospital, aged 27 to 58 years, including 10 cases with degree Ⅲ thumb defect and 2 cases with degree Ⅳ thumb defect after thorough debridement. The thumb was reconstructed with free hallux-nail flap combined with composite tissue flap of the second phalangeal bone, joint, and tendon with skin island. The donor site of hallux-nail flap was covered with artificial dermis in the first stage and performed with continuous vacuum sealing drainage, and covered with medium-thickness skin graft from the groin site in the second stage. The donor site in the second toe was filled and fixed with iliac bone strips. The survival of reconstructed thumb was observed 1 week after the reconstruction surgery, the survival of skin graft in the donor site of hallux-nail flap was observed 2 weeks after skin grafting, and the callus formation of the reconstructed thumb phalanx and the second toe of the donor foot was observed by X-ray 6 weeks after the reconstruction surgery. During the follow-up, the shape of reconstructed thumb was observed and the sensory function was evaluated; the function of reconstructed thumb was evaluated with trial standard for the evaluation of the functions of the upper limbs of the Hand Surgery Society of the Chinese Medical Association; whether the interphalangeal joints of the hallux and the second toe were stiff, the scar hyperplasia of the foot donor site, and whether the walking and standing functions of the donor feet were limited were observed. Results: One week after the reconstruction surgery, all the reconstructed thumbs of the patients survived. Two weeks after skin grafting, the skin grafts in the donor site of hallux-nail flap of 11 patients survived, while the skin graft in the donor site of hallux-nail flap of 1 patient was partially necrotic, which was healed completely after 10 days' dressing change. Six weeks after the reconstruction surgery, callus formation was observed in the reconstructed thumb and the second toe of the donor foot of 10 patients, the Kirschner wires were removed; while callus formation of the reconstructed thumb was poor in 2 patients, and the Kirschner wires were removed after 2 weeks of delay. During the follow-up of 6 to 24 months, the shape of reconstructed thumb was similar to that of the healthy thumb, the discrimination distance between the two points of the reconstructed thumb was 7 to 11 mm, and the functional evaluation results were excellent in 4 cases, good in 6 cases, and fair in 2 cases. The interphalangeal joints of the hallux and the second toe of the donor foot were stiff, mild scar hyperplasia was left in the donor site of foot, and the standing and walking functions of the donor foot were not significantly limited. Conclusions: The application of free hallux-nail flap combined with the second toe composite tissue flap in the reconstruction of damaged thumb after electrical burns adopts the concept of reconstruction instead of repair to close the wound. It can restore the shape and function of the damaged thumb without causing great damage to the donor foot.

Three-Dimensional Computer-Aided Design Modeling and Printing for Accurate Toe-to-Hand Transplantation

To introduce toe-to-hand transplantation performed with the assistance of both bone and soft tissue modeling using 3-dimensional printing technology. From May 2015 to October 2018, 31 patients (group A, 24 thumbs and 7 fingers) were included. Computed tomography scans were acquired using a spiral computed tomography scanner, and the data were processed with software. Bone, skin, and nail models were created for tailoring the flap taken from the great toe. The impact of foot pathology in terms of pain, disability, and activity restriction was assessed using the Foot Function Index. For comparison, we included 35 patients (group B) who underwent toe-to-hand transplantation without the assistance of 3-dimensional computer-aided modeling. The mean duration of follow-up of groups A and B was 26 months (range, 24-31 months) and 27 months (range, 24-33 months), respectively. The mean Foot Function Index of groups A and B was 5 (range: 0-15) and 17 (range, 0-39), respectively. Three-dimensional computer-aided modeling and printing provide geometric accuracy in toe-to-hand transplantation. It also may reduce the donor foot morbidity by accurate flap designing and harvesting. Therapeutic IV.

Long-term donor-site morbidity after thumb reconstruction with twisted-toe technique.

Traumatic thumb loss is aserious injury affecting patient´sability to work and participate in activities of daily life. The main goal for aplastic surgeon is to restore hand grip, often by microsurgical methods. However, patients should be informed of all effects associated with tissue harvesting. The aim of the study was to assess the impact on donor foot and gait cycle in patients who have undergone thumb reconstruction using twisted-toe technique modified by Kempný. Twelve patients participated in the study: all suffered athumb loss between the years 2003 and 2011 and the twisted-toe technique for thumb reconstruction was utilized. The changes in foot pressure distribution and lower extremity joint loading were evaluated. The differences in total maximal plantar pressure, pressure time integral, contact area, and maximum force between the affected and non-affected foot were statistically significant (P 0.1). No significant differences of temporal gait parameters between the affected and non-affected extremity were observed; however, statistically significant differences in kinetics parameters, frontal ankle and knee moments were detected. Donor limb functionality and anatomical disability were assessed using pedobarography systems and 3D-gait analysis. The recorded differences in plantar pressure distribution (increased pressure in I., IV. and V. metatarsal areas) and overload of the medial compartment of the knee joint were the most significant findings. Therefore, wearing individually adapted shoe insoles as prevention of osteoarthrosis might be beneficial for patients after thumb reconstruction by atwisted-toe technique.

Long-Term Outcomes After Toe-To-Thumb Transfers for Burn Reconstruction in Children.

Children are one of the most vulnerable populations to burns, and hands are frequently burned anatomical structures. Restoring function in a severely burned pediatric hand is challenging. We present our experience with pediatric toe-to-thumb transfers for burn reconstruction. A retrospective review was conducted of all pediatric toe-to-thumb transfer patients between 2009 and 2014. Children younger than the age of 18 who underwent secondary reconstruction after electrical or thermal burn injuries with at least a 5-year follow-up were included. Functional outcomes were measured with the modified Kapandji score. Complications of the reconstructed hand as well as the donor foot were recorded. Four children with 10 toe-to-hand transfers (four great toes, two second toes, and two combined second-third toes) met the inclusion criteria. The average follow-up length was 104 months (range 60-144 months). Two children sustained thermal burn injuries and two sustained electrical burn injuries. Three children achieved opposition of the reconstructed toe-to-thumb transfer to the small finger (Kapandji score 5), and one child achieved opposition of the reconstructed toe-to-thumb transfer to the proximal phalanx of the middle finger, the only remaining finger (Kapandji score 3). No donor foot morbidities were noted postoperatively. Toe-to-thumb transfers should be considered the standard of care for thumb reconstruction in children with severe burn injuries of their hands to provide restoration of sensation, pinch, grasp, and opposition with minimal morbidity of the donor foot.

Salvage Reconstruction of a Congenital Hypoplastic Thumb Due to Constriction Ring Syndrome Using a Third Toe Transfer, When the Usual Donor Sites of Index Finger, Great and Second Toes Are Not Available.

Isolated third toe-to-thumb transfers have been rarely reported and none in the pediatric population. We describe a third toe-to-thumb transfer for reconstruction of a congenital hypoplastic thumb with excellent functional results and no morbidity in the donor foot.

Clinical Application of Doppler Ultrasound Imaging Technology in Thumb Reconstruction

Objective: In order to increase the survival rate of clinical thumb reconstruction, the Doppler ultrasound (DU) imaging technology based on the minimum variance adaptive beamforming (MV) algorithm is applied to the preoperative examination of thumb reconstruction. Method: 75 patients who needed thumb reconstruction were divided into 40 study group and 35 traditional group. Before operation, color Doppler ultrasound was used to examine saphenous vein, radial artery in the receiving area, dorsalis pedis artery and cephalic vein in the donor area to determine whether there was abnormality. In addition, the branch type of toe web and the Gilbert type of the first dorsal metatarsal artery were examined and confirmed. Through ultrasound examination, the operation plan was determined. In the traditional group, through doctor's pen Doppler auscultation or touch feeling, the great saphenous vein-dorsalis pedis vein-dorsal metatarsal veins-dorsal digital veins of foot was dissected in the traditional way without ultrasonic examination. The MV algorithm was used to process the ultrasonic image. Results: The ultrasonic image processed by MV algorithm is clearer and higher quality. There is no absence of dorsalis pedis artery in the contralateral donor area in 75 patients. There is no vascular crisis in the study group and one patient in the traditional group. The average operation time in the Gilbert III study group is 90 minutes, compared with 135 minutes in the traditional group. There is no walking pain of donor foot in the study group after Gilbert III operation, and there are three walking pain in the traditional group. Conclusion: The MV algorithm can be used in thumb reconstruction. It can detect the branch type of toe web and the Gilbert type of the first dorsal metatarsal artery. On this basis, the operation plan can be determined, which can reduce the blindness of the operation, shorten the operation time, increase the survival rate of the reconstructed thumb, and reduce the incidence of complications of the donor foot.

Use of single-staged transmetatarsal trimmed great toe transfer for reconstruction of a thumb amputation at the carpometacarpal joint

Reconstruction for proximal thumb amputation at the carpometacarpal (CMC) joint level is extremely challenging. All thenar muscles are lost and other fingers might be lost or injured. Transmetatarsal trimmed great toe (TGT) transfer may be an option in such cases. Between 2012 and 2018, 11 patients who had amputation of the thumb at the CMC joint level were reconstructed by transmetatarsal TGT transfer in a single stage. There were seven cases in which the right hand was affected and four cases in which the left hand was affected. Three cases involved a contracture scar at the thumb stump and required web space reconstruction. Average follow-up was 33.9 months (range: 12-76 months) RESULTS: All toe transfers survived. The average of static two-point discrimination (S2PD) was 14.6 mm; the average scores of the Quick Disabilities of the Arm, Shoulder, and Hand (quickDASH) questionnaire and the Michigan Hand Outcomes Questionnaire (MHQ) were 18.6 and 73.8, respectively. Two cases did not achieve opposition due to mispositioning of the neothumb. In nine cases achieving opposition, the Kapandji score ranged from 4 to 9, pinch ranged from 3 to 11 lbs, and grip ranged from 15 to 86 lbs. In the donor foot, three patients had neuroma and two had a new callus on the palmar side of the second and third metatarsal heads. The average foot and ankle disability index score was 91.6. Single-staged transmetatarsal TGT transfer is safe and useful for thumb reconstruction at the CMC joint level. This reconstructive method is suitable for manual workers, especially in the developing countries.

Type IIIB and IV hypoplastic thumb reconstruction with non-vascularized fourth metatarsal.

We treated 16 patients with 17 hypoplastic thumbs (eight Type IIIB and nine Type IV) using a non-vascularized fourth metatarsal transfer with a rotational flap and multi-staged reconstruction. The average age at the first operation was 24months. The average follow-up time was 46months. All patients achieved reasonable hand function and were able to use the reconstructed thumb to grip small and large objects. The operated thumb achieved an average Kapandji score of 6.7 and average pinch strength of 0.9 kg. There were two cases of graft nonunion. All parents are satisfied with the function and appearance of the reconstructed thumb and donor foot. We conclude that non-vascularized fourth metatarsal transfer is a feasible reconstruction method for patients with Types IIIB and IV hypoplastic thumbs. The reconstruction allows for the preservation of a 5-digit hand with reasonable function and appearance and minimal donor site morbidity, although long-term growth of the metatarsals still need to be monitored.Level of evidence: IV.

Reversed vascularized second metatarsal flap for reconstruction of Manske type IIIB and IV thumb hypoplasia with reduced donor site morbidity.

The predominant method for Manske type IIIB and IV thumb hypoplasia is pollicization. However, for those who are not willing to sacrifice the index finger, a method that could reconstruct a functionally capable and aesthetically acceptable thumb remains desirable. This study aimed to investigate and assess the functional and radiographic outcomes of utilizing a reversed vascularized second metatarsal composite flap for thumb reconstruction as a new alternative. From May 2014 to January 2017, 15 patients with Manske type IIIB or IV thumb hypoplasia who were admitted to the Department of Hand Surgery, Beijing Jishuitan Hospital were included in this study. An osteocutaneous flap containing a section of second metatarsal and its distal head was transferred in reversed position to reconstruct carpometacarpal joint. The donor site was reconstructed by a split half of the third metatarsal. Various functional reconstructions were commenced at second stage. The reconstructed thumbs were evaluated using the Kapandji score, pinch force, and the capacities of performing daily activities through a detailed questionnaire. Among these 15 patients (seven type IIIB and eight type IV), there were ten boys and five girls with median age of 4.2 years (range: 2.0-7.0 years). There were seven right, three left, and five bilateral thumbs for whom only the right thumb received surgery. There were 14 metatarsal flaps survived (14/15). With an average follow-up of 19.2 months, the reconstructed thumbs had acceptable functional and aesthetic outcomes and the donor foot presented in decent appearance without signs of impaired function. All 15 children have improved the Kapandji score (from 0 to an average of 6.7), pinch force (from 0 to an average of 1.5 kg), with ability of grip and pen holding. X-ray indicated continuous bone growth. Patients and parents had good acceptance of the new thumb. Reconstruction of an unstable hypoplastic thumb (Manske type IIIB and IV) with use of a vascularized metatarsal is an effective strategy. It offers an alternative solution for parents insisting on saving the thumb.

Repair of thumb defect by using the toenail flap: biomechanical analysis of donor foot\u2014a retrospective cohort study

BackgroundThe thumb accounts for 50% of the total hand function. This study reports the functional outcomes and complications of people with traumatic thumb amputations who underwent toe-to-thumb reconstruction.MethodsFrom January 2013 to January 2018, 29 patients with second-degree thumb defect underwent thumb reconstruction with distal phalangeal braided toenail flap. The footscan foot pressure gait analysis system was used to measure the index changes of the same foot before and after 1, 3 and 6 months. The contact area, peak pressure, impulse value, contact time of each gait phase, centre of gravity coordinate and foot balance were analysed statistically.ResultsTwenty-nine cases of thumb reconstruction recovered well. After following up for 6–15 months, the appearance of the reconstructed thumb was close to normal, and the sensation was restored to S3+. The two-point discrimination was 6–8 mm, and the function of the thumb was good. The function of the donor foot was well restored, and no skin ulceration, pain and claudication were noted during walking. Compared with that before the operation, the biomechanical indices of the donor foot were basically restored to normal 6 months after the operation. Only the stress and impulse values of the third metatarsal head were significantly increased, forming a stress concentration area centred on the third metatarsal head.ConclusionsThis study confirmed that the toenail flap with distal phalangeal bone restored the second-degree thumb defect without destroying the main functional structure of the sole. The biomechanical indices of the donor foot were basically restored to normal 6 months after the operation. Only the stress concentration area centred on the third metatarsal head, and the pain on the forefoot was induced after the operation. Discomfort, callus formation, metatarsal fasciitis, etc., can lead to fatigue fracture of the third metatarsal bone in severe cases, which requires further follow-up and observation.Trial registrationClinicaltrials.gov, NCT03879941; registered on 10 March 2019, retrospectively.

Thumb Amputations in Children: Classification and Reconstruction by Microsurgical Toe Transfers

Traumatic amputations of the thumb are rare in children compared with adults, but hand surgeons remain reticent to consider microsurgical reconstruction with toe-to-thumb transfers. This study reports the functional outcomes and complications of children with traumatic thumb amputations who underwent toe-to-thumb reconstruction. A retrospective review of children who sustained thumb amputations and whose parents elected for their child to undergo reconstruction by toe-to-thumb transfer was performed. Details of the level of thumb amputation, whether other fingers were also amputated, which toe was transferred on which vascular pedicle, survival of the transfer, and complications, were collected. Opposition, sensation, and growth of the toe-to-thumb transfers was measured. Functional and psychosocial outcomes were evaluated by both the parents and the older children using the Pediatric Outcomes Data Collection Instrument questionnaire. Twenty-one thumb amputations in 19 children between the ages of 2 and 17 years were referred for secondary reconstruction. Ten were isolated thumb amputations and 11 were combined thumb and multiple finger amputations. Two children had bilateral thumb amputations. Twenty-one toe-to-thumb transfers were performed: 14 second toe transfers and 7 great toe transfers (3 great toe and 2 trimmed and 2 Morrison wraparound variations). There were no immediate postoperative reexplorations of the microsurgical anastomoses and all toe transfers survived completely. All children regained pinch and grasp function and sensation. There were no gait problems in the donor feet. Microsurgical toe-to-thumb transfers should be offered as an alternative option to the traditional techniques of distraction lengthening and pollicization, for posttraumatic thumb reconstruction in children for any level of amputation from just distal to the carpometacarpal joint to the interphalangeal joint. Toe-to-thumb transfer provides length, opposition, and sensation without disturbing ambulation and is associated with excellent psychosocial outcomes as evaluated by both parents and older children. Therapeutic IV.

Repair of cicatricial contracture deformity of palm with modified free medial plantar flap with preserved abductor hallucis

To investigate the effectiveness of modified free medial plantar flap with preserved abductor hallucis for repairing cicatricial contracture deformity of palm. Between January 2012 and July 2017, a modified free medial plantar flap with preserved abductor hallucis was used to repair 9 cases of cicatricial contracture deformity at the palm. There were 7 males and 2 females with a median age of 23 years old (range, 15-40 years). The duration of cicatricial contracture was 4-23 years (mean, 9 years). In addition, 3 cases had combined stiffness of finger joints, 2 cases of tendon exposure, and 2 cases with exposed tendon and nerve. The range of flap was 4.5 cm×4.0 cm to 8.0 cm×6.0 cm. The vessel pedicle of the flap was 7-8 cm in length, with an average length of 7.5 cm. Grafting and repairing were performed with full-thickness skin graft from the ilioinguinal region in the donor site. All flaps and skin grafts survived after operation, and all wounds healed at first intention. All 9 patients were followed up 5-22 months (mean, 10 months). The flap exhibited smooth appearance and soft texture, which was similar to that of the normal skin around. The recovery time of dermal sensation was 5-12 months (mean, 9 months). At last follow-up, the flap recovered to level S 4 in 5 cases, level S 3 in 3 cases, and level S 3 in 2 cases. The two-point discrimination was 6.0-10.0 mm (mean, 8.5 mm). According to the assessment of the upper limb function issued by the Hand Surgery Society of Chinese Medical Association, the hand function was excellent in 5 cases, good in 2 cases, and fair in 2 cases. Additionally, the abduction and flexion activities of the great toe of the donor foot were not affected, and the skin grafting area was slightly colored. The modified free medial plantar flap for repairing cicatricial contracture deformity of palm has such advantages as no impact on abductor hallucis, small damage of the donor area, improved survival rate of skin grafting, and the unaffected function of the donor foot.

Application of lower leg perforator flap for repair of the soft tissue defects in the donor site of toe transplantation

Objective To explore the clinical effects of lower leg perforator flap in the treatment of the soft tissue defects in the donor site of toe transplantation. Methods From December 2015 to December 2016, 15 cases of thumb or finger defects were reconstructed by the transplantation of big toe nail flap, the fibula side flap of great toe and second toe wrap-around flap. Simultaneously, the free peroneal artery perforator flap or posterior tibial artery perforator flap was used to repair the soft tissue defects in donor site of toe transplantation. Results All the reconstructed fingers and thumbs survived. All the flaps used to cover donor site of the foot survived. The follow-up time ranged from 1 to 18 months with an average of 8.6 months. The donor site of toe transplantation recovered well without influence on wearing shoes and walking. According to the Maryland foot function scoring system issued by Sanders et al, the results were rated as excellent in 14 cases and good in 1 case. Conclusion Lower leg perforator flap for repair of the soft tissue defects in the donor site of toe transplantation can not only reconstruct the good appearance and function of thumbs and fingers, but also can restore the integrity of donor foot. The function and appearance of the foot are well recovered. Key words: Surgical flaps; Treatment outcome; Soft tissue defects; Toe donor site

Clinical experience of finger reconstruction with toe transplantation in children

Objective To investigate the feasibility and long-term efficacy of reconstructing thumb and fingers with toe transplantation in children. Methods From June 2005 to December 2015, 11 cases (16 fingers) were reconstructed with toe transplantation. There were 8 thumbs, 6 index fingers, and 2 middle fingers. Results All the reconstructed fingers survived. Necrosis of skin grafts at the donor site was seen in 1 case, but healed after changing dressings. All the patients were followed-up from 1 to 5 years. The growth and development of the reconstructed fingers were satisfactory. The function of grip was regained. Two-point discrimination was 5 to 8 mm. According to the functional assessment criteria for thumb and finger reconstruction issued by the Hand Surgery Society of the Chinese Medical Association, the outcomes were excellent in 8 cases and good in 3 cases. There was no abnormal gait and pain in the donor foot. The function of the foot was not impaired. Conclusion The outcomes of toe transplantation in reconstruction of thumb and finger defects in children were satisfactory. Key words: Toes; Tissue transplantation; Finger defects; Child