Free Toe Research Articles

Vascularized Partial Free Toe Tissue Transfer Under Local Anesthesia

This study was designed to introduce free toe soft tissue transfer using local infiltration anesthesia in patients not suitable for general anesthesia and local tissue coverage. From January 2006 to August 2012, a total of 11 traumatic fingertip defects were reconstructed by toe soft tissue transfer. All procedures except 1 were done as primary reconstructions, with either the lateral side of the great toe (5 cases) or the medial side of the second toe (6 cases) used as a donor. Postoperative follow-up periods were between 8 months to 2 years and 6 months. Flap sizes varied from 1.0 × 2.0 to 2.0 × 3.5 cm. The mean operative times were 4 hours 29 minutes for cases done by a single team and 3 hours 21 minutes for cases done by a 2-team approach. Approximately 5.8 mL of local anesthetic agent was used in each finger and 5.9 mL was used in the toes for a total of 11.7 mL. All flaps survived and were fully taken without complications, except 1 case that presented partial necrosis. Fingertip soft tissue reconstruction by free toe tissue transfer under local anesthesia uses a more limited operative field, with a shorter operative time, enabling reconstruction in patients not suitable for general anesthesia. This is even more so with a microsurgical 2-team approach, which reduces the volume of anesthetic agent needed, making this method a sufficiently realistic option for fingertip soft tissue reconstruction.

Free lateral great toe flap for the reconstruction of finger pulp defects.

The aim of this study was to evaluate the esthetic and sensory outcomes after reconstruction of finger pulp defects with free toe flaps from the lateral aspect of the great toe. From June 2006 to October 2011, we performed 48 free toe pulp transfers for finger pulp reconstruction in 43 patients; 18 male and 25 female patients with a mean age of 31.8 years (range, 16-47 years). Six patients suffered multiple digital pulp defects and five received two synchronous pulp transfers. The defects involved 20 thumbs, 15 index fingers, 10 long fingers, and 4 ring fingers, and flap size ranged from 24 × 18 to 55 × 30 mm. Follow-up evaluation included the functional and esthetic outcomes of the reconstructed pulps and donor toes. All but one flap survived completely. Overall, 32 cases (35 pulp flaps) were followed for more than 1 year (range, 12-48 months; average, 22.8 months). The Semmes-Weinstein sensitivity score was 2.83 to 4.74 at the flaps and the mean static two-point discrimination was 6.17 mm (range, 3-10 mm). A total of 13 patients (40.6%) experienced mild (10 cases) to moderate (3 cases) cold intolerance, and 1 patient (3.1%) suffered severe cold intolerance. According to the Michigan Hand Outcome Questionnaire the mean esthetic appearance score was 16 (range, 12-19). The free neurovascular great toe pulp flap is an efficient and reliable flap for the reconstruction of finger pulp defects.

Repair of nail bed defect of the fingers by free great toe dorsofibular nail flap transfer

Objective To introduce the surgical techniques and clinical results of repairing defects of the finger nail bed with free great toe dorsofibular nail flap transfer.Methods From December 2011 to February 2013,dorsofibular nail flap of the great toe based on the great toe fibular dorsal artery was applied to repair defects of the finger nail bed in 10 cases.These defects involved the thumb in 7 cases,the index finger in 2 cases,and the middle finger in 1 case.The size of the defects ranged from 8 mm × 12 mm to 13 mm × 21 mm.The donor sites were covered with full-thickness skin grafts.Results All 10 great toe dorsofibular nail bed flaps survived completely.Complete survival of the skin graft and primary healing at the donor site was seen in 8 cases.Necrosis at the edge of the skin graft occurred in 2 cases which was treated with dressing change and healed secondarily.Postoperative follow-up ranged from 9 to 23 months,with an average of 15 months.Nails that grew back at the recipient thumb or finger were smooth,shiny and plump in appearance.Walking function of the donor foot was not affected.There was no pain.Conclusion Transfer of the great toe dorsofibular nail bed flap is an ideal procedure for treatment of different types of finger nail bed defects. Key words: Tissue transplantation; Microsurgery; Nail bed injuries

POSTERIOR INTEROSSEOUS FLAP IN PEDIATRIC HAND RECONSTRUCTIONS

Purpose: to assess early and long-term results of the pediatric hand reconstructions with posterior interosseous flap, including those in children younger than 3 years old. Materials and methods: results of the hand reconstructions with posterior interosseous artery reverse flap were studied in 10 children (4 males and 6 females) aged from 1 year and 1 month to 13 years old. In 4 cases flap coverage were performed due to acquired posttraumatic hand deformity, in 6 cases reconstruction was assumed for congenital hand deformities. Combined procedures consisted of posterior interosseous artery flap coverage and other types of microsurgical reconstructions were suggested in 4 patients. Preoperative color doppler visualization of the posterior interosseous vessels were mandatory. All flaps were risen under 3.5x-4.5x magnification. Results: all flaps survived completely in 3 weeks postoperatively. There were no postoperative complications such as flap’s arterial or venous insufficiency, deep infection, or posterior interosseous nerve palsy. Nearly whole group (9 of 10) of patients and/or their parents were satisfied with the esthetic view of the reconstructed hand and donor site of the forearm 1 year postoperatively. Conclusion: posterior interosseous flap is a reliable and versatile option in pediatric hand reconstructions, providing excellent skin coverage with good color match and texture. Preservation of major vascular bundles of the forearm (radial and ulnar arteries) during flap harvest gives a possibility to perform a simultaneous microsurgical reconstructions of the hand (e.g. free toe transfer).

Treatment of monodactyly in adults with bilateral free second toe transplantation

Objective To evaluate the application of bilateral second toe transfer for reconstruction of congenital monodactyly in adults.Methods Five adult patients with congenital monodactyly were treated between January 2000 and October 2011 by transferring second toes from both feet to reconstruct the index and middle fingers.All 5 patients showed that only one hand was involved with a near normal thumb and no fingers.Postoperative evaluations included range of motion,moving two-point discrimination,grip strength,key pinch,Jebsen-Taylor hand assessment and patient questionnaire on appearance.Results The patients were follow-up after the surgery for 14 months to 6 years.All the transplants survived.Protective sensation was restored in all the reconstructed fingers.Range of motion was 12° at the distal interphalangeal joint,22° at the proximal interphalangeal joint and 74° at the metacarpophalangeal joint.Grip strength and key pinch were 25.5 ％ and 74.5 ％ of the contralateral hand respectively.Jebsen-Taylor hand assessment indicated that the involved hand could manage basic activities.The average visual analogue score (VAS) was 8.Conclusion Bilateral second toe transfer is a valid procedure for finger reconstruction in adults with congenital monodactyly. Key words: Hand deformities, congenital; Tissue transplantation; Adults

Repair of different types of nail bed defect by free toe nail flap

Objective To investigate the clinical application of free nail bed flap from the toe in the treatment of different types of nail bed defects of the finger.Methods Twelve cases of fingernail bed defects were treated with transplantation of free nail bed flap of various shapes from the toe based on the type and shape of nail bed defect.Donor site of the toe could be closed directly in 5 cases,while a fibular toe flap pedicled on the dorsal digital artery and skin graft was used to close the donor site wound in 7 cases.Results The 12 transferred toe nail bed flaps all survived,as well as the fibular toe llaps and skin grafts at the donor site.Patients were follow-up for 1 to 18 months,with an average of 7 months.Appearance of the reconstructed fingernails was satisfactory.Varying degrees of contracture of the nail were seen in 4 cases.Finger function was good.There was no obvious scar and blister formation at the donor site.Walking was not affected.Concclusion Transfer of free nail bed flap from the toe is an ideal method to t-eat different types of nail bed defects of the finger. Key words: Tissue transplantation; Microsurgery; Nail bed injuries

Aesthetic and Sensory Reconstruction of Finger Pulp Defects Using Free Toe Flaps

This study illustrates aesthetic and sensory reconstruction of finger pulp defects with free toe flaps from the lateral aspect of the great toe or the medial aspect of the second toe. Between August 2007 and July 2010, free toe flaps were harvested and used for 21 fingers of 21 patients. The average patient age was 34.5years (range 19-62years). The soft tissue defects were found in the thumb of 6 patients, the index finger of 7 patients, the middle finger of 5 patients, and the ring finger of 3 patients. The donor site was the great toe for 9 patients and the second toe for 12 patients. The average flap size was 2.8×2.0cm (range 1.7×1.7 to 3.5×3.0cm). Restoration of the sensitivity, aesthetic appearance, and mobility of the injured fingers compared with the opposite side was assessed using appropriate tools during the follow-up time. All the flaps in this series survived completely, with a high survival rate of 100%. No urgent operative revision necessitated by postoperative thrombosis of the vessels was performed during the follow-up period. During a mean follow-up period of 18.4months (range 12-24months), the average static two-point discrimination score for the injured finger pulp was 4.8mm (range 3-7mm), and the Michigan Hand Outcome Questionnaire score was 4.9mm. The mean range of motion of the distal interphalangeal joint in the injured finger was 69.7°. Transplantation of free microvascular flaps from the great toe or the second toe is a useful and reliable technique for finger pulp defect reconstruction. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Free toe transplantation for finger reconstruction

Objective To investigate the effect of free toe transplantation in finger reconstruction.Methods Free toe transplantations were performed in 164 patients (185 fingers) suffering from finger defection.There were 134 males and 30 females,aged at 12-83 years [mean (44.8 ± 11.2)years].Finger deletion severity was classified as grade Ⅰ in one case,grade Ⅱ in 18,grade Ⅲ in 23,grade Ⅳ in 49,grade Ⅴ in 54,and grade Ⅵ in 19.According to Gilbert standards,dorsal metatarsal arteries were classified as type Ⅰ in 68 cases,type Ⅱ in 84,and type Ⅲ in 12.Survival ratio of the transplanted fingers and hand function rehabilitation were observed.Results The transplanted toe survived in 160 cases (173 fingers).They composed of all the cases of grade Ⅰ-Ⅴ finger deletion and 15 cases of grade Ⅵ finger deletion; all the cases of type Ⅰ dorsal metatarsal arteries,83 cases of type Ⅱ dorsal metatarsal arteries and nine case of type Ⅲ dorsal metatarsal arteries.Transplantation failed in four cases (12 fingers) of grade Ⅵ finger defection including one case of Gilbert Ⅱ dorsal metatarsal arteries and three cases of Gilbert Ⅱ dorsal metatarsal arteries.Postoperative results were excellent in 110 cases and good in 50.Conclusions Toe transplantation is helpful to restore the finger shape and function and the outcome is satisfactory.Anatomic deformation of dorsal metatarsal arteries is the main cause for the failure of finger reconstruction. Key words: Finger injuries ; Toe Joint ; Transplantation

Combined transfer of the free second toe dorsal wrap around flap and fibula side flap of great toe to repair degloving injury of the single finger

Objective To provide the new method for repairing degloving injury of the single finger. Methods From August 2007 to June 2010, eleven patients were repaired with the second free toe dorsal wrap around flap and fibula side flap of great toe. Patients including 9 men and 2 women. The mean age were 31 years （17-49 years）. The finger including 6 index fingers, two middle fingers and 3 ring fingers, in which 4 patients were type Ⅰ and 7 patients were type Ⅱ. All of them were emergency debridement VSD closed negative pressure attraction, surgical repair in 3-5 days after injury. The plantar digital nerve in the second free toe dorsal wrap around flap and fibula side flap of great toe with the digital nerve of the stump by end-to-end nerve anastomosis. The donor sites were covered with a free flap. Results All of 11 flaps sur- vived, but 2 cases developed partial native second toe skin grafting necrosis, by dressing healed, one case of phalanges exposed through survival skin, the part of the exposed phalanx healed after surgical cut. All the 11 patients were followed up from 3 monthes to 3 years. The flaps survived completely with satisfactory cosmetic results and good sensibility. The sensation recovery was reached above S3. The great toe fibular flap for repair of finger pulp full, two-point discrimination was 6-9 mm, the mean was 7.0 mm. Finger flexion function by finger total activity （TAM） score assessment, excellent 9 cases, good 2 cases. Conclusion Transfer of the second free toe dorsal wrap around flap and fibula side flap of great toe to repair degloving injury of the sin- gle finger is an ideal method of treatment. Key words: Second toe of nail skin flap; Fibula side flap of the great toe; Finger; Degloving in-jmy

Fingertip Reconstruction Using Free Toe Tissue Transfer Without Venous Anastomosis

BackgroundThis study was designed to introduce the feasibility of toe tissue transfer without venous outflow for fingertip reconstruction.MethodsFive cases of fingertip defects were treated successfully with this method. Four cases were traumatic fingertip defects, and one case was a hook-nail deformity. The lateral pulp of a great toe or medioinferior portion of a second toe was used as the donor site. An arterial pedicle was dissected only within the digit and anastomosis was performed within 2 cm around the defect margin. The digital nerve was repaired simultaneously. No additional dissection of the dorsal or volar pulp vein was performed in either the donor or recipient sites. Other surgical procedures were performed following conventional techniques. Postoperative venous congestion was monitored with pulp temperature, color, and degree of tissue oxygen saturation. Venous congestion was decompressed with a needle-puncture method intermittently, but did not require continuous external bleeding for salvage.ResultsVenous congestion was observed in all the flaps, but improved within 3 or 4 days postoperatively. The flap size was from 1.5×1.5 cm2 to 2.0×3.0 cm2. The mean surgical time was 2 hours and 20 minutes. A needle puncture was carried out every 2 hours during the first postoperative day, and then every 4 hours thereafter. The amount of blood loss during each puncture procedure was less than 0.2 mL. In the long-term follow-up, no flap atrophy was observed.ConclusionsWhen used properly, the free toe tissue transfer without venous anastomosis method can be a treatment option for small defects on the fingertip area.

Reconstructing finger hemiarthrosis injury with free second toe hemiarthrosis graft

Objective To report the clinical results of applying free second toe hemiarthrosis to repair finger hemiarthrosis injury,and discussed the countermeasures of relative problems. Methods From June 2005 to January 2010, thirteen fingers of 13 patients with traumatic finger joint injury had repaired by using vascularized second toe hemiarthrosis graft. Results All 13 grafted fingers survived,and all wounds were primary healing.The time of follow-up was between 1.5 and 4.5 years,average of 3.2 years.All grafted joints were healed and the remaining joints were normal in morphology and structure, except for 1 patient subluxation with dorsal slightly convex.No degenerative changes happened to the grafted joints.No pain and no joint instability phenomenon.Nonunion and re-fracture phenomenon did not appear.The average extension of joint motion was 0°.The average flexion was 80°.Healing of the foot donate areas were satisfactory,and did not affect walking function.Using TAM assessment method of the hand joint function,the excellent rate was 90％. Conclusion The way of using free second toe hemiarthrosis to repair finger hemiarthrosis injury could achieve satisfactory clinical efficacy.To completed set-up of transplanted joint structure and function units,a delicate surgery were improved to be important factors of the surgical treatment. Key words: Finger ; Joint ; Second toe ; Transplantation ; Microsurgical operation

Long-term Donor Site Morbidity After Free Nonvascularized Toe Phalangeal Transfer

Free nonvascularized toe phalangeal transfer is an established surgical option for the reconstruction of hypoplastic digits. This study assessed long-term morbidity in the feet using this technique. We reviewed 40 children treated between 1991 and 2007 by free nonvascularized toe phalangeal transfer. The diagnosis was digital hypoplasia resulting from symbrachydactyly in 33 cases, constriction ring syndrome in 3 cases, thumb hypoplasia in 3 cases, and perinatal subclavian venous thrombosis in 1 case. The patients were followed up after surgery for a mean of 10 years (range, 3-19 y). The Oxford Ankle Foot Questionnaire was administered to patients and families to assess patient symptoms and patient and parental satisfaction. We assessed toe length ratio, the presence of visible deformity, and distal hypoplasia of the donor toes clinically and radiographically. Emotional problems related to foot appearance were common. We also found functional problems with footwear in some patients. All patients had floppy unstable toes with visible deformity. Increasing foot deformity was seen with growth, which led to deterioration in foot aesthetics, particularly where multiple donor toes had been harvested. We identified distal and middle phalangeal and metatarsal hypoplasia in the donor toes. Donor site morbidity for free toe phalangeal transfer is greater than previously documented. This should be considered during surgical decision making for reconstruction of hypoplastic digits. Preoperative counseling should include discussion regarding possible consequences of phalangeal harvest on donor toes and options for donor site reconstruction. Long-term follow-up of the donor site is essential to accurately assess results. Therapeutic III.

Free great toe wrap-around flap combined with second toe medial flap for reconstruction of completely degloved fingers

Free great toe wrap-around flap combined with second toe medial flap for reconstruction of completely degloved fingers

Communicating Branch of Toe Web Veins as a Venous Return Pathway in Free Toe Pulp Flaps

Communicating Branch of Toe Web Veins as a Venous Return Pathway in Free Toe Pulp Flaps

Clinical study of thumb tip defect reconstruction with free distal second toe in emergency

Objective To discuss the clinical therapeutic efficacy of the clinical study of thumb tip defect reconstruction with free distal second toe in emergency. Methods Fifteen cases of thumb tip defect were reconstructed with free distal second toe in emergency.The blood supply was restored by anastomosis of digital and toe'S artery and nerves,the dorsal surface and other side vein of fingers all can be anastomosed with toe's vein.but the first was main. Results All of fifteen fingers survived.Followed-up from 3 months to 3 years,all reconstruction thumbs has a satisfying outward appearance,normal nail and fingerprint,well pinch and hold functions, none effect to the foot. Conclusion Repair of thumb tip defects using free distal second toe in emergency enables favorable functional recovery and satisfying outward appearance,the method is simple and rats recover quickly. Key words: Finger tip; Toe; Transplantation; Thumb; Microsurgery

Free second toe one-stage-plasty and transfer for thumb or finger reconstruction

Free second toe one-stage-plasty and transfer for thumb or finger reconstruction

A new surgery treatment for thumb reconstruction by one-stage plasty free second toe transfer

Objective To investigate a more pedect method for a nice outward appearance of a reconstructed thumb.Methods A free one-stage plasty second toe transfer for thumb reconstruction by interchanging the whole skin-nail flap from the great toe with another one from the second toe.Results There were 12 cases in this group,following-up 6-9 months in 8 cases,7 cases was excellent and 1 cases was good.The reconstructed thumb got a nice looking and more normal function while no blight to the great toe occurred.Conclusion It is an effective new procedure in ameliorating outward appearance of the reconstructed thumb by transferring the free moulded second toe. Key words: Toe; Transfer; Skin-nail flap; Thumb; Reconstruction; Microsurgery

Die sekundäre Rekonstruktion des Daumens nach Avulsions- oder Amputationsverletzung mit dem Wrap-around-toe-Flap

The free wrap-around toe flap, first described by Morrison in 1980, represents an option for a tailor-made reconstruction of the thumb. This technique ensures flexibility, length, sensibility and an excellent aesthetic outcome. The morbidity rate of the donor site is negligibly small. Unfavourable and therefore limiting to the indication is the absence of a possibility for a joint transfer, the lack of growth potential and the risk of bone absorption when using an iliac bone graft. Our small series includes 5 patients with an average follow-up time of 11.4 months (range: 6 - 22 months) treated from 2003 - 2006. The static two-point discrimination on average was 19 mm (range: 4 - 39 mm). All patients describe coldness intolerance. As there is no deficit in performing opposition and pinch power, there is an acceptable motion of all thumb joints. All patients report a good subjective outcome and would undergo the operation once again. In spite of the short follow-up period with moderate to good results, the wrap-around toe flap can be recommended as an appropriate and safe procedure for thumb reconstruction after an avulsion and traumatic amputation.

Precision grip function after free toe transfer in children with hypoplastic digits

Precision grip function after free toe transfer in children with hypoplastic digits

Treatment alternatives of congenital hand differences with thumb hypoplasia involvement

Congenital thumb hypoplasia is a complex and heterogeneous congenital difference that is detrimental to hand function. Apart from its' classic form, which is now considered to be part of radial dysplasia, it can occur as part of other congenital anomalies including, syndactyly, symbrachydactyly, atypical cleft hand, bifid thumb, triphalangeal thumb, mirror hand, constriction band syndrome, as well as generalized anomalies and syndromes. Management is aimed primarily at restoring basic hand function, specifically, power grasp and precision pinch, and secondarily to improve cosmoses, which inevitably is going to be impaired. Several treatment alternatives have been proposed to manage the specific disabling condition and include, 1st web space reconstruction and opponensplasty, pollicization, toe-to-hand transfer, distraction lengthening, free toe phalangeal transfer or the use of allograft, stabilization of the metacarpophalangeal joint, and surgery of "spare parts." The purpose of this study is to evaluate the various alternatives available today and propose an algorithm applicable for the appropriate management of thumb deficiency, based on their specific characteristics.