Free Toe Research Articles

Free neurovascular toe-(joint)-transfers compared to alternative reconstructive procedures for amputation injuries of two and tripartite fingers with substance loss.

Complex injuries of the hand frequently result in loss of essential functional features. Common reconstructive procedures for soft tissue defects of the thumb or phalanges are locoregional flaps like Moberg-, Foucher-, Cross-Finger- or Littler flaps. Microneurovascular toe (joint-) transfers complete the arsenal of operative reconstructive procedures and allow for most detailed reconstructions. Our experiences with free toe transplants are reported and diversely discussed regarding contending procedures. From 2010 until 2019 14 patients who received emergency or elective partial or complete toe transfers were compared with a control group (n = 12) treated with contending reconstructive procedures. Aim of the reconstructions was to cover the defect with well-vascularized, sensate tissue, while preserving length and range of motion in a reliable manner. The Kapandji score showed a significant difference (p- value = 0.04) with a score of 9.8 in comparison to control group (Kapandji index = 8.0). In our heterogenic patient collective free toe transplants have proven to achieve comparable functional results for reconstruction of two and tripartite phalanxes as opposed to common local reconstructive procedures.

Lambda Repair: A Novel Repair Technique for Chronic Boutonnière Deformity.

Correction of a boutonnière deformity is one of the most demanding challenges in hand surgery. Surgical interventions are usually considered when functional use of the finger cannot be obtained after intense hand therapy. The authors introduce their newly described lambda (λ) repair, which is an easy-to-learn, straightforward surgical technique. The method involves an end-to-side tenorrhaphy of the lateral bands, resembling the Greek λ. Patients who underwent a lambda repair were retrospectively evaluated with preoperative and postoperative measurements of proximal interphalangeal (PIP) joint movement. Four patients (two male, two female; median age, 35.5 years) with a median follow-up period of 9.1 months were included. Three patients underwent lambda repairs for isolated boutonnière deformities, and one patient received a vascularized free toe transfer combined with a lambda repair. The preoperative average PIP joint extension lag or deficit was 28.75 degrees and could be reduced to 15 degrees. Preoperative average PIP joint active flexion was 60 degrees, which was improved to 88.75 degrees. No complications were observed. The lambda repair is a new tool in the reconstruction of boutonnière deformity, further expanding the armamentarium of hand surgeons.

Результаты аутотрансплантации второго пальца стопы в позицию утраченного первого пальца кисти

Defects of the thumb negatively impact physical and mental health, lead to depression, inferiority complex and hopelessness in the future. The aim of the study was to explore long-term results of thumb reconstruction using autologous transplantation of the second toe with microvascular anastomoses. Material and methods Second toe transplantation for thumb reconstruction was performed for 54 patients. There were 48 male and 6 female patients aged from 12 to 55 years. When analyzing the long-term results of surgical treatment of patients. The anatomy and functionality of the repaired finger was evaluated at a long term measuring the range of motion in the joints, muscle strength of the hand and major types of hand grips. Results The autograft completely healed with opposition of the reconstructed thumb and the rest fingers restored in 51 patients. The autograft failed in three cases treated with less functional methods. Conclusion Microsurgical reconstruction technologies used for a lost thumb facilitated rapid recovery of the finger and significantly improved functions of the injured hand as an entity. Free second toe transplantation using microvascular anastomoses for the thumb reconstruction allowed the patient regain basic gripping functions and improve cosmesis of the injured hand.

Full-Thickness Skin Grafts for Coverage of the Pedicle in Partial Second Toe Pulp Free Flap

Pedicle coverage during free flap reconstruction of the digit commonly presents complicated issues. As the finger is a cylindrical unit with small volume, it is difficult to secure ample soft tissue for relaxed coverage of the pedicle. We have applied full-thickness skin grafts (FTSGs) to loosely cover the pedicle of the free flap of the fingertip and report preliminary results. Seven patients who received free toe pulp flap and FTSG for soft tissue coverage of the pedicle were analyzed. Intraoperative parameters collected were defect, flap and graft area size and donor site. Patients were observed postoperatively for up to 2 months for graft take, necrosis, digit contour, and donor site complications. The average area of the free flap was 2.39±1.03 cm<sup>2</sup> and the average graft area was 1.37±1.06 cm<sup>2</sup>. The FTSG survived without sloughing or necrosis in six patients. Early epithelial sloughing with dermis take was noted in one patient who healed with dressings. The pedicle and graft portion showed bulging immediately after the operation but decreased to normal contour by 4 weeks. FTSG is an option that can be safely used as a method of pedicle coverage during free flap reconstruction of digits.

Nonvascularized Free Toe Phalangeal Transfers in Congenital Hand Differences: Radiological, Functional, and Patient/Parent-Reported Outcomes

To evaluate radiologically, functionally and by patient-reported outcome measures, nonvascularized free toe phalangeal transfer (NVFTT) in the reconstruction of congenital short fingers with redundant soft tissue. Nineteen children who underwent NVFTT in 40 digits were studied. Of these, 13 patients with a mean follow-up of 5.2 years were assessed radiologically for epiphyseal patency, growth, growth rate, and length comparison with the contralateral toe. Eight children were available for an in-person follow-up. In these patients, we measured the pinch strength and range of motion. The Pediatric Outcomes Data Collection Instrument; the upper extremity, depression, anxiety, pain interference, and peer relationships domains of the Patient-Reported Outcomes Measurement Information Systems; and the aesthetic component of the Michigan Hand Questionnaire were used for the assessment of psychosocial impact. An open epiphysis was found in 24 of 31 grafts. Among these, 20 of 21 grafts were in 9 children younger than 18 months and 4 of 10 grafts were in children older than 18 months at the time of operation. The mean growth was 3.4 mm. The mean growth rate was 1.3 mm/y. Length was 71.8% of the contralateral phalanx. The key pinch strength was 1.3 kg (2.6 kg on the normal side). The mean range of motion at the metacarpophalangeal joint was-4° to 65° flexion. Two proximal interphalangeal joints were stiff and 2 had range of motion of 0° to 30°. Children evaluated with Pediatric Outcomes Data Collection Instrument had high mean scores in all domains. The Patient-Reported Outcomes Measurement Information Systems scores were low for the upper-extremity domain. On the aesthetic component of the Michigan Hand Questionnaire, children gave higher scores than parents. Donor toes, though short, did not cause a functional disability. NVFTT reliably provides length, stability, and movement in short fingers with redundant soft tissue. In addition to good radiological and clinical outcomes, the patient-reported outcome measures support performing NVFTT in children. Surgery before 18 months, extraperiosteal harvests of grafts, and avoidance of tight skin closures are important. Therapeutic IV.

Cosmetic and functional results of a newly reconstructed thumb by combining the phalanx of second toe and the great toenail flap transplantation

BackgroundMicrosurgical toe-to-hand transfer is a gold standard when it comes to repairing a thumb defect. Great toenail flap, thumbnail valva flap, free great toe, and second toe transplantation are the common methods in thumb reconstruction. Second toe transplantation achieves good function, but poor esthetics. Great toe transplantation achieves better esthetics, but hindered walking, due to the foot’s loss of the great toe and moreover suboptimal thumb function. It is difficult to maintain both functional and esthetic satisfaction in thumb reconstruction.MethodsWe experimented with three different methods of toe to hand transfer. From October 2009 to July 2019, 30 patients with traumatic thumb defects received one of 3 different kinds of thumb reconstruction in our clinic according to their level of amputation. Divided evenly into three groups of ten, group one received a great toe transplantation, group two received a second toe transplantation, and group three received a combined great toenail flap and second toe phalanx transplantation. Each of the patients’ thumbs had different levels of amputation at the metatarsophalangeal joint (MPJ) or distal interphalangeal joint (DIPJ).ResultsOne patient suffered from a partial flap necrosis and received a groin flap to cover the defect. No other thumbs had any complications. The functional and esthetic results of both the donor and the recipient sites were satisfactory. Results show that, for patients with traumatic thumb defects, the combined transfer of flap and second toe phalanx was the best option.ConclusionsCompared to the great toe or second toe transfer, combined free transfer of the great toenail flap and second toe phalanx achieved a substantially better functional and esthetic result in the thumb reconstruction.

Importance of preserving redundant pulp skin in thumb terminalization to allow subsequent reconstruction with on-top toe transfer: A clinical case (with video)

Traumatic thumb amputations can seriously jeopardise hand function. Several alternatives for reconstructing an opposable thumb have been described, including distraction osteogenesis, index finger pollicisation and free toe transfer. We present in this article the case of a young male patient that sustained a circular saw injury to his non-dominant thumb which resulted in loss of his distal phalanx. Preserving the sensate pulp allowed later reconstruction with an on-top free second toe transfer achieving a satisfactory outcome.

Application of free big toe nail bone flap combined with second toe tibial flap for reconstruction of thumb defect

Objective To introduce a modified method of thumb reconstruction by combined transplantation of free big toe nail bone flap and second toe tibial flap. Methods According to the condition of thumb defect, free big toe nail bone flap and second toe tibial flap with the common vascular pedicle were cut from the first and second toes of the ipsilateral foot. The second toe tibial flaps were transversely transferred to the tibial side of the toe nail bone flap to reconstruct the toe nail flap belly and nail folds, improve the shape of the reconstructed thumb and reduce the damage of the donor site. Results All the 7 cases survived and the donor and recipient wounds achieved primary healing. The postoperative follow-up period ranged from 3 to 15 months. The reconstructed thumb had good appearance and normal function. According to the functional evaluation criteria of the upper limb issued by the Hand Surgery Society of Chinese Medical Association, the results were graded as excellent in 5 cases and good in 2 cases. All the patients could manage their activities of daily living independently. The donor site had little injury, good shape and function. Conclusion The method of reconstructing thumb defect with free big toe nail bone flap combined with second toe tibial flap can effectively improve the appearance of reconstructed thumb, make the reconstructed thumb symmetrical, beautiful and functional, and reduce the damage of donor toes. Key words: Thumb; Surgical flaps; Second toe; Reconstruction

Application of free modified first toe web skin flap for repair of finger web defect

Objective To explore the repair method and clinical efficacy of finger web defect of hand. Methods From January 2014 to December 2017, 7 cases with finger web defects were repaired by the first toe web flaps. Full-thickness abdominal skin grafts were used in all donor sites. Results All the 7 flaps survived and the donor site healed well. The follow-up period ranged from 6 to 12 months with an average of 8 months. The appearance and sensation of the free first toe web flaps recovered well after the operation. There was no obvious contracture in the reconstructed finger webs. The abduction angle was close to the normal finger web. There was no obvious scar hyperplasia in the donor site, and the walking function of the foot was good. Conclusion It is a better method to repair finger web defect with the first toe web skin flap, which can achieve satisfactory appearance and function of the hand. Key words: Surgical flaps; Transplantation; Finger webs; Microsurgery

Investigating Patients' Perception of Microvascular Free Toe Flap for Reconstruction of Amputated Thumbs: A Guide for Surgeons during Informed Consent.

After thumb amputations, restoration of function and aesthetic can be accomplished with microvascular free toe flaps. However, many patients in clinical practice do not choose this reconstruction despite positive reported outcomes. This study aims to determine patients' perceptions with respect to free toe flaps to improve areas of informed consent. A retrospective survey was administered to patients with thumb amputations. Participants were required to complete a questionnaire about patient demographics, the Brief Michigan Hand Questionnaire (bMHQ), the standard gamble/time trade-off questionnaires for utility scores, and a questionnaire investigating potential reasons for electing not to undergo a free toe transfer. Thirty patients were enrolled in the study wherein 53% underwent a replantation procedure, 27% a revision amputation, and 20% a delayed reconstruction. Mean normalized score on the bMHQ was recorded as 63.54. Utility questionnaires yielded mean measures of 0.8967 and 0.86 on the standard gamble and time trade-off, respectively. From 14 elements, a majority (87%) stated flap failure as a major source of concern, followed by lack of understanding of risks and benefits (80%) and prolonged hospital stay (53%). Cultural/religious beliefs, aesthetic appearance of the foot, and concerns about footwear were not reported as important reasons in 90, 80, and 79% of patients, respectively. A better understanding of patients' attitudes and beliefs with respect to free toe flaps will allow surgeons to better address their concerns during informed consent. This study emphasizes the importance to discuss about failure rates, risks, and benefits of the operation and prolonged hospital stay.

Free second toe transplantation with the first dorsal metatarsal artery flap in reconstruction of thumb and repair of adjacent finger wound

Objective To explore the surgical method and clinical effects of free second toe transplantation with the first dorsal metatarsal artery flap in reconstruction of thumb and repair of adjacent finger wound. Methods From June 2010 to June 2015, 9 cases of thumb defect and adjacent finger soft tissue defects were treated using free second toe transplantation with the first dorsal metatarsal artery flap. The area of the first dorsal metatarsal artery flap ranged from 3.3 cm×2.0 cm to 5.2 cm×3.0 cm. Free skin grafts were used to repair donor site. Results Postoperatively tension blister at the distal end of the flap occurred in 1 case which were healed after removal of stitches and change of dressing. Other reconstructed fingers, flaps and skin grafts achieved primary healing. All the patients were follow-up for 6 to 32 months with an average of 15 months. All the flaps presented good appearance and elasticity with soft texture. The appearance and function of the reconstructed thumbs were good. There was no obvious effect on foot load walking. No skin ulcer occurred in donor site. Conclusion Free second toe transplantation with the first dorsal metatarsal artery flap in reconstruction of thumb and repair of adjacent finger wound is an ideal method for repairing due to the reliable blood supply, safe operation and accordance to repair principle. Key words: Surgical flaps; Microsurgery; Tissue defects; Repair

Ulnar Thumb Pulp Reconstruction Using the Anterograde Homodigital Neurovascular Island Flap.

The thumb ulnar pulp is a critical component of key pinch and precision manipulation. Injuries to this area should be reconstructed with robust, sensate tissue that restores bulk and contour. The existing reconstructive options, however, have substantial risks and drawbacks. We describe an anterograde homodigital neurovascular island flap that provides both sensate and durable coverage of the ulnar thumb pulp. The flap uses innervated glabrous tissue, limits donor site morbidity to the thumb and first web space, and does not require microvascular anastomoses or nerve coaptation. The flap has been previously described for nonthumb fingertip injuries, but it has not been applied to the thumb. We discuss several important technical modifications that are essential to raising and insetting this flap in the thumb, review potential pitfalls, and highlight key steps to ensuring judicious intraoperative decision making and success.

Free tibial second toe flow-through flap for repair of finger wound with artery defect

Objective To explore the clinical effects of free tibial second toe flow-through flap for repair of finger wound with artery defect. Methods From July 2005 to January 2016, 12 cases of volar soft tissue and artery defects of fingers were covered by free second toe medial flap, and proper digital artery defect was bridged by proper plantar digital artery of tibial second toe to restore the blood supply of distal finger. The donor site was repaired by full-thickness skin graft. Blood flow was detected by Doppler probe 1 month after operation. Results Postoperatively all the flaps survived uneventfully. The appearance and texture of the flap were satisfactory. No dysfunction occurred in donor sites. All the patients were follow-up for 6 to 36 months with an average of 18 months. The fingertips were warm without cold intolerance. Blood flow of bridged arteries was detected by Doppler probe. Two-point discrimination of the flaps was 8 to 12 mm with an average of 10 mm. No ulceration occurred in the skin graft of donor sites. Wearing shoes and walking were not affected. Conclusion The texture of free tibial second toe flow-through flap is good. It is an ideal method to repair volar soft tissue and artery defects of fingers at one-stage. Key words: Surgical flaps; Finger injuries; Flow-through flaps

Reconstruction of full-length thumb and fingers by segmental bridging severed finger using emergency free second toe composite tissue flap

Objective To investigate the surgical technique and clinical effect of segmental bridging severed finger using emergency free second toe composite tissue flap in reconstruction of full-length thumb and fingers. Methods From June 2007 to June 2015, 16 patients whose proximal segment of the thumb and fingers was damaged and distal part was relatively intact were treated by segmental bridging severed finger using emergency free second toe composite tissue flap to reconstruct the full-length thumb and fingers. Results All 16 reconstructed full-length fingers survived uneventfully. The follow-up period ranged from 5 to 18 months. The reconstructed finger tip sensory function recovered well. Extensor tendon adhesion occurred in 9 cases which underwent tenolysis as secondary surgery. The functional recovery of the remaining reconstructed fingers was good. According to the functional evaluation standards of reconstruction of thumb and finger issued by Hand Surgery Society of the Chinese Medical Association, the results were excellent in 4 cases, good in 9 cases, fair in 3 cases. Conclusion It is feasible for segmental bridging severed finger using emergency free second toe composite tissue flap to reconstruct full-length thumb and fingers. The postoperative effect is satisfactory. It is a recommended method for full-length finger reconstruction. Key words: Surgical flaps; Treatment outcome; Second toe; Reconstruction; Full-length finger

Modified method of Hallux toe nail flap for finger tip reconstruction and donor site repair

Objective To discuss the modified method and clinical effect of free hallux toe nail flap for reconstruction of composite tissue defect at finger tip and repair of its donor site. Methods Partial nail bed at fibular side of hallux was cut and combined with toe tip skin to form hallux toe nail flap. The reconstruction of finger tip defects was achieved by free hallux toe nail flap transplantation. The donor site of hallux was sutured directly. Nail bed wound was healed by itself without skin graft or flap repair. From May 2013 to April 2015, 13 cases (15 fingers) had partial nail bed and skin defects at finger tip and no obvious distal phalanx defects, which were repaired by this method. Results All the patients were follow-up for 3 to 12 months. All the free hallux toe nail flap graft survived. The finger tip appearance and nail growth were close to normal. The function of interphalangeal joint was good. Hallux nail was nearly complete with good appearance and without obvious defect. No local pain, ulceration, and sensory disorder occurred at hallux donor site. Conclusion Hallux toe nail flap is an ideal method for reconstruction of composite tissue defect at finger tip. The improvement of donor site repair method can make better appearance of toe tip and nail without obvious sequelae. Key words: Finger injuries; Surgical flaps; Free tissue flaps; Fingertip defects

Microsurgical Digital Reconstruction by Vascularized Free Toe Pulp Transfer

Background: Restoring the aesthetic appearance and sensibility of the fingers, specially the fingertip, after traumatic amputation has an essential role in the functional recovery of the hand. Advances in microsurgery have allowed better coverage of defects with low morbidity of the donor site. Purpose: Our purpose is to present the clinical and functional outcomes achieved by vascularized free toe pulp transfer for fingertip reconstruction in hand labor patients with medium to high functional demand. Method: Between March of 2011 and August of 2015, 18 patients underwent free toe pulp transfer to restore finger pulp defects. All were manual workers, 16 men and 2 women, and their average age was 39 (25-53) years. Fourteen patients suffered from traumatic partial amputations and 4 patients had high-pressure injection injury. The average time from the accident to surgery was 18 (8-30) days. Overall results were evaluated in terms of survival flap rate, complications, and additional surgical procedures. Static 2-point discrimination (s2-PD), satisfaction, and time to return to work were also assessed with a mean follow-up more than 1 year postoperatively. Results: The survival rate was 100%. Donor site required a split-thickness skin graft (STSG) in 11 cases. Good functional results and a high degree of satisfaction were obtained. Average s2-PD over the flap area was 9.1 (8-11) mm. All patients returned to heavy manual work. Conclusion: In our opinion, the use of free toe pulp transfer provides the best aesthetic and functional outcomes in digital pulp reconstruction. It provides not only a satisfactory appearance but also excellent functional results and allows patients to return to heavy manual works.

Adeno-Associated Virus-2–Mediated VEGF Gene Transfer to the Tendon Improves the Healing Strength of the Digital Flexor Tendons

Purpose: A major challenge in repairing injured digital flexor tendon is the weak intrinsic healing capacity of tendon, which is responsible for rerupture of repaired tendon after primary repair. In an experimental model of transection and surgical repair of the digital flexor tendon in chicken toes, we aim to test the effectiveness of introducing the vascular endothelial growth factor (VEGF) gene through an adeno-associated virus (AAV) vector to enhance tendon healing strength. Materials and Methods: One hundred and eighteen flexor digitorum profundus (FDP) tendons in the long chicken toes were completely transected the in zone 2 and surgically repaired using 2-strand modified Kessler method. These toes were divided into two groups: 58 FDP tendons (group 1) were injected with 2 × 109 particles of AAV2-VEGF per tendon and 62 tendons (group 2) after injection with saline. The toes were immobilized in semiflexed position for the first 3 weeks and then released for free toe motion. At postoperative 1, 2, 3, 4, 6, and 8 weeks, the ultimate strengths of the healing tendons were tested in an Instron tensile testing machine. At weeks 4, 6, and 8, the work of digital flexion (WOF) was also recorded and adhesions around the repair site scored. We also supplemented a group (20 toes) in which only empty AAV2 vector was injected to the tendon, and tendon strength and adhesions were recorded at weeks 2 and 4. Results: Delivery of AAV2-VEGF significantly increased ultimate strength of the healing tendons at postoperative weeks 3, 4, 6, and 8 ( P < .05 or P < .01). At week 4, the tendon strength was 12.4 ± 8.6 N after AAV2-VEGF injection, but 5.7 ± 1.1 N after saline injection. At week 6, the strength was 46.4 ± 19.2 N after AAV2-VEGF injection, but 27.1 ± 8.9 N after saline injection. At week 6 and 8, the adhesion scores and WOF of the toes after AAV2-VEGF injected were not increased. We found no significant increases in the strength of the tendon after injection of sham vector compared with that in saline control group. Conclusions: The results of this study show the therapeutic efficacy of AAV2-VEGF for improvement of tendon healing strength without aggravating adhesion formation after surgical tendon repair. AAV2-VEGF therapy appears to be a promising method of biological modulation of healing of the digital flexor tendons.

TOE FIBULAR-DORSAL ARTERY FLAP ANASTOMOSED TO DORSAL DIGITAL ARTERY IN REPAIRING DORSAL SOFT TISSUE DEFECT OF FINGERS

To discuss the effectiveness of free toe fibular-dorsal artery flap anastomosed to dorsal digital artery in repairing dorsal soft tissue defect of fingers. Between May 2010 and September 2015, 28 patients with dorsal soft tissue defect of fingers were treated, including 17 males and 11 females with an average age of 23.8 years (range, 15-55 years). The reasons of injuries were machine twist (15 cases), heavy pound (4 cases), the sharp cut (5 cases), and hot crush (4 cases). The time from injury to admission was 30 minutes to 12 hours (mean, 1.5 hours). The involved fingers included thumb (3 cases), index finger (8 cases), middle finger (6 cases), ring finger (6 cases), and little finger (5 cases). The area of soft?tissue?defects ranged from 2.0 cm×1.5 cm to 3.5 cm×2.5 cm, and the area of free toe fibular-dorsal artery flap ranged from 2.8 cm×1.7 cm to 3.8 cm×2.8 cm. The blood supply of the flaps were reconstructed by anastomosing the toe fibular-dorsal artery, vein, and nerve to the dorsal digital artery, vein, and nerve, respectively. The donor site was repaired by free skin graft. The operation time was 1.5-5.5 hours (mean, 2.5 hours); the blood loss during operation was 10-50 mL (mean, 30 mL). Vessel?crisis?occurred?in?1 case, and the flap survived after symptomatic treatment. The other flaps survived and the wounds healed with stage I; the skin grafts at donor site survived and the incisions healed with stage Ⅰ. Twenty-eight cases were followed up 6-24 months (mean, 8 months). The appearance of flaps was good, and two-point discrimination was 3.5-12.0 mm (mean, 5.3 mm) at 6 months after operation. The fingers function of grab and pinch recovered. According to the standard functional evaluation issued by Hand Surgery Association of Chinese Medical Association, the results were excellent in 20 cases and good in 8 cases, with an excellent and good rate of 100% at 6 months after operation. The donor sites of toe were smooth and had no depression. The patients had normal gait. Free toe fibular-dorsal artery flap anastomosed to dorsal digital artery in repairing dorsal soft tissue defect of fingers can obtain satisfactory effectiveness in appearance and function of fingers, and has the advantages of modified repair and less injury at donor site.

Free toe pulp flap for finger pulp and volar defect reconstruction.

Background:Fingertip injury requiring flap cover is very common in the modern era. The ideal cover should fulfill both functional and aesthetic improvement.Materials and Methods:From June 2015 to April 2016, we performed seven free toe pulp flaps for finger defect reconstruction. All patients were males. Five flaps were done in emergency post-traumatic cases, and two were done in elective set up. The cases included reconstruction of three thumbs, one index and one ring finger in an emergency set up and two ring fingers in the elective. Thumb reconstruction was done with great toe lateral pulp and the other digits reconstructed with second toe pulp flap. Follow-up evaluation included both functional and aesthetic assessment.Results:Five flaps survived completely, one suffered partial loss, and one flap failed completely. The median follow-up period was 9 months. The median duration of surgery was 255 min (range 210 to 300 min). The median two-point discrimination was 6.5 mm (range 4–8 mm). There was the return of temperature sensation in all patients; two had cold intolerance. The Semmes-Weinstein monofilament score varied from 3.61 to 5.07 (median filament index value 4.31/pressure value of 2 g/mm2). Three patients had delayed donor site wound healing.Conclusions:The free toe pulp flap is an efficient choice for fingertip and volar finger defects reconstruction with an excellent tissue match.

Free Pulp Transfer for Fingertip Reconstruction-The Algorithm for Complicated Allen Fingertip Defect.

We present a review of all the cases of free toe pulp transfer and an algorithm for application of free pulp transfer in complicated Allen fingertip defect. Seventeen patients underwent free toe pulp transfer for fingertip reconstruction by the senior author. Twelve cases were Allen type II with oblique pulp defect, 4 were Allen type III, and 1 patient had 2 fingertip injuries classified both as type IV. According to the algorithm presented, for the type III defects where the germinal matrix is still preserved, we use free pulp transfer and nail bed graft to preserve the nail growth instead of toe to hand transfer. For the type IV injuries with multiple defects, a combination of web flap from both big toe and second toe is possible for 1-stage reconstruction. All pulp flaps survived completely. Static 2-point discrimination ranged from 6 to 15 mm (mean: 10.5 mm). No patient presented dysesthesia, hyperesthesia, pain at rest, or cold intolerance. The donor site did not present any nuisances apart from partial skin graft loss in 3 cases. We tried to classify and modify the defects' reconstruction according to Allen classification. Free toe pulp transfer is a "like with like" reconstruction that provides sensate, glabrous skin with good color and texture match for fingertip trauma, and minimal donor site morbidity compared with traditional toe to hand transfer.