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An Alternative Thumb Reconstruction by Double Microsurgical Transfer From the Great and Second Toe for a Carpometacarpal Amputation

2018; Elsevier BV; Volume: 43; Issue: 10 Linguagem: Inglês

10.1016/j.jhsa.2018.03.022

1531-6564

Ignacio Roger de Oña, Andrea Garcia Villanueva, Alexis Studer de Oya,

Reconstructive Facial Surgery Techniques

Thumb amputation at the carpometacarpal level is very incapacitating. Pollicization may be considered. We describe an alternate technique for thumb reconstruction at the level of the metacarpal base using a trimmed great toe along with a vascularized second metatarsophalangeal joint, including the second metatarsal, all supplied on a single vascular pedicle. Two patients who had a combined soft tissue defect and amputation of the thumb close to the carpometacarpal joint were reconstructed with this method. A transposition of the second toe was performed on top of the remaining proximal phalanx of the great toe to decrease donor site morbidity. This technique provides adequate length to the thumb without compromising another finger by creating a new thumb using a double microsurgical toe transfer on a single vascular pedicle. We minimize donor site morbidity by transposing the second toe onto the great toe. Thumb amputation at the carpometacarpal level is very incapacitating. Pollicization may be considered. We describe an alternate technique for thumb reconstruction at the level of the metacarpal base using a trimmed great toe along with a vascularized second metatarsophalangeal joint, including the second metatarsal, all supplied on a single vascular pedicle. Two patients who had a combined soft tissue defect and amputation of the thumb close to the carpometacarpal joint were reconstructed with this method. A transposition of the second toe was performed on top of the remaining proximal phalanx of the great toe to decrease donor site morbidity. This technique provides adequate length to the thumb without compromising another finger by creating a new thumb using a double microsurgical toe transfer on a single vascular pedicle. We minimize donor site morbidity by transposing the second toe onto the great toe. Posttraumatic amputation of the thumb causes a substantial loss to hand function especially if it is at the base of the metacarpal. The thumb contributes between 40% and 50% of hand function. In addition, it possesses the unique ability to circumduct and oppose, making it indispensable when performing activities such as pinch, grasp, and fine manipulation that are essential in daily life. Restoring both function and aesthetic appearance of the hand after traumatic loss of the thumb is the main goal of thumb reconstruction. Selection of the method to be used depends on a variety of factors, such as the level of amputation, presence of other injuries to the same hand, patient preferences, and surgeon experience. Multiple techniques have been described to restore the native thumb ranging from osteoplastic techniques,1Givissis P. Stavridis S.I. Ditsios K. Christodoulou A. One-stage thumb lengthening with use of an osteocutaneous 2nd metacarpal flap.Strategies Trauma Limb Reconstr. 2009; 4: 135-139Crossref PubMed Scopus (3) Google Scholar pollicization,2Ishida O. Taniguchi Y. Sunagawa T. Suzuki O. Ochi M. Pollicization of the index finger for traumatic thumb amputation.Plast Reconstr Surg. 2006; 117: 909-914Crossref PubMed Scopus (25) Google Scholar to different microsurgical toe transfers.3Wei F.C. Chen H.C. Chuang C.C. Chen S.H. Microsurgical thumb reconstruction: selection of various techniques.Plast Reconstr Surg. 1994; 93: 345-351Crossref PubMed Google Scholar When dealing with an amputation through, or just distal to, the carpometacarpal (CMC) joint, the principal difficulty is providing adequate bone length and soft tissue coverage including a suitable first web space to the reconstructed thumb. Pollicization of the index finger is usually the recommended technique for reconstruction of the thumb at this level, but there are also different techniques of toe-to-thumb transfers for such thumb reconstruction. When the injury involves the adjacent fingers, pollicization may be precluded. The first dorsal metatarsal artery (FDMA), originating from the dorsalis pedis artery, provides the primary vascular pedicle for the great and second toe, which have been used to create different models of compound flaps for thumb reconstruction.4Tsai T.M. D'Agostino L. Fang Y.S. Tien H. Compound flap from the great toe and vascularized joints from the second toe for posttraumatic thumb reconstruction at the level of the proximal metacarpal bone.Microsurgery. 2009; 29: 178-183Crossref PubMed Scopus (17) Google Scholar, 5Koshima I. Kawada S. Etoh H. Saisho H. Moriguchi T. Free combined thin wrap- around flap with a second toe proximal interphalangeal joint transfer for reconstruction of the thumb.Plast Reconstr Surg. 1995; 96: 1205-1210Crossref PubMed Scopus (19) Google Scholar We describe an alternate technique for thumb reconstruction at the level of the metacarpal base using a trimmed great toe along with a vascularized second metatarsophalangeal (MTP) joint, including the second metatarsal, all supplied by a single vascular pedicle. Two patients who had a combined soft tissue defect and amputation of the thumb close to the CMC joint were reconstructed with this method. Transposition of the second toe on top of the proximal phalanx of the great toe was performed as well in order to improve foot appearance and function. Indications for performing this technique are thumb amputations at the base of the first metacarpal. Contraindications do not differ from the general contraindications for microsurgical techniques. The first step requires identifying the presence of the FDMA using a Doppler probe. Next, measurements of the healthy contralateral thumb are taken, including the length and the circumference of the normal thumb as well as the length of the first metacarpal. These dimensions are transferred onto the ipsilateral toe. A zigzag incision is made on the dorsum of the foot down to the first web. The incision then proceeds around the great toe and a cutaneous strip is left on the medial side. Proximal palmar and dorsal V flap extensions are also included in the lateral side of the great toe (Fig. 1). Under tourniquet without exsanguination, the dorsal approach on the foot is used to expose the subcutaneous veins and the FDMA. Once the vessels are isolated, the dissection proceeds distally up to its bifurcation into the dorsal digital arteries of the first and second toe. Special attention should be paid to protecting the articular branch of the second MTP joint, during the dissection in the interosseous space. Osteotomies are performed at different levels on each toe's proximal phalanx. A third osteotomy is done at the base of the second metatarsal to provide adequate thumb length (Fig. 2). The flap from the great toe is incised and the trimmed toe is elevated as described by Wei et al.6Wei F.C. Chen H.C. Chuang C.C. Noordhoff M.S. Reconstruction of the thumb with a trimmed-toe transfer technique.Plast Reconstr Surg. 1988; 82: 506-515Crossref PubMed Scopus (94) Google Scholar At this point, we prefer to also expose the plantar digital artery of the great toe and dissect it in case we may need an extra vascular supply. The second MTP joint with the distal two-thirds of the metatarsal shaft is isolated and elevated without the overlying skin or extensor or flexor tendons. The tourniquet is released to check perfusion of the composite tissue flap made up of the trimmed toe and a vascularized second MTP joint including the second metatarsal, using the FDMA as a single pedicle (Fig. 3). If necessary, the vessels can even be dissected proximally by extending this dissection up into the lower leg.Figure 2Dotted lines represent the 3 osteotomies. Great toe osteotomy is performed in the middle of the proximal phalanx. Second toe osteotomies are performed at the base of the proximal phalanx and in the proximal third of the second metatarsal.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Double microsurgical transfer from the first and second toes. DDA, dorsal digital arteries; EHL, extensor hallucis longus tendon; FHL, flexor hallucis longus tendon; IM, interosseous muscle.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The proximal phalanx of the great toe is fixed to the distal portion of the MTP joint using K-wires or double interosseous wiring with perpendicular (90°–90°) configuration. The wires are twisted, leaving the ends turned laterally to avoid impinging on the tendons. The medial side of the great toe that was previously debulked is now sutured (Fig. 4). A transposition of the second toe on top of the remaining proximal phalanx of the great toe is performed, as reported by Del Piñal et al.7Del Piñal F. Garcia-Bernal F.J. Regalado J. Studer A. Ayala H. Cagigal L. A technique to improve foot appearance after trimmed toe or hallux harvesting.J Hand Surg Am. 2007; 32: 409-413Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Toe fixation is achieved with 2 1-mm crossed K-wires. The medial flap that was elevated from the great toe to reduce its size is now interposed in the medial aspect of the second toe, achieving an enlargement effect (Fig. 5). Two more 1.8-mm K-wires are inserted between the first and third metatarsal to approximate the bones. Antiplatelet therapy with oral aspirin (100 mg daily) is prescribed for 1 month. The limb is immobilized with an above-elbow cast at 45° elbow flexion for 10 days, after which the cast is then removed and a bulky dressing is placed for 1 more week. Protected walking is permitted after 7 days. The patient is allowed to walk with a normal gait in 5 weeks, when the K-wires are removed. Low doses of heparin are maintained during that time. After 4 weeks, the patient is referred to our therapy department to start with protective mobilization and assisted active motion exercises. Unrestricted motion of the thumb was allowed at 10 weeks, when bone fusion was confirmed radiographically. 1.During dissection of the articular branch of the second MTP joint, a small cuff of muscle is left attached to the metatarsal bone to preserve vascularization.2.Double interosseous wiring with perpendicular (90°–90°) configuration is the preferred method for the thumb bone fixation.3.Perform the osteotomies at a different level on the proximal phalanx of the first and second toe because this will allow a gain in length on the pedicle because it needs to travel from the lateral to the medial side once both phalanges are fixed together. A 54-year-old man sustained an amputation of the thumb at the metacarpal base of his dominant right hand from a press machine (Fig. 6). The thenar muscles were partially preserved. We performed a single-stage thumb reconstruction 3 months later using a combined great toe and second toe transfer, all supplied by the first dorsal metatarsal artery as a single vascular pedicle. In addition, a free gracilis muscle flap was transferred to provide soft tissue coverage over the metacarpal, allowing us to widen the first web space (Fig. 7). The compound flap was then transferred to the hand where a 2.3-mm plate and screws were used to fix the proximal end of the second metatarsal to the remnant of the first metacarpal. Tendons were sutured in the usual fashion at the wrist level. The digital nerves of the flap were coapted to the corresponding digital nerves of the thumb. The FDMA and 2 dorsal veins were anastomosed end to end to the radial artery at the snuffbox and subcutaneous veins of the dorsum of the hand. The medial femoral circumflex vessels were anastomosed end to side to the radial artery and a subcutaneous vein at the wrist level. A split-thickness skin graft was placed on the muscle. The flap survived. One year after injury, the patient was able to write and oppose the reconstructed thumb, scoring 5 on the Kapandji score (Fig. 8). Pinch strength was 9 pounds on the right side and 18 pounds on the left side. Static 2-point discrimination was 10 mm on the pulp. He returned to his previous work. He was also able to walk without difficulties and with normal gait 3 months after surgery. He was pleased with the cosmetic and functional result at both donor and recipient sites. A 23-year-old man sustained a crush-avulsion amputation of the right thumb at the CMC joint with associated ring and little finger amputations (Fig. 9). Eight months after injury, a complete thumb reconstruction was performed using this technique. The newly formed thumb was stabilized to the hand. Tendons were repaired and both plantar nerves were coapted to the nerve stumps of the thumb using a superficial peroneal nerve graft. The first web space was reconstructed with a simultaneous anterolateral thigh flap (ALT) using the ulnar artery and a superficial vein at the wrist as recipient vessels. Flow-through arterial anastomosis of the thumb was performed between the FDMA and the descending branch of the lateral circumflex femoral artery while an end-to-end venous anastomosis was performed using a superficial vein in the hand. During the insetting of the flap, we noticed that small changes in thumb positioning interrupted the arterial perfusion, so we decided to use a temporary external fixator to avoid complications (Fig. 10). One year after injury, the patient was able to achieve pulp-to-pulp pinch with the index finger, pulp-to-lateral pinch with the middle finger, and write normally (Fig. 11), but he could not return to his previous work. Pinch strength was 7 pounds on the right side and 14 pounds on the left side. He recovered only protective sensation without measurable static 2-point discrimination. No changes in gait pattern were found. The patient was, nonetheless, highly satisfied with the outcome. Thumb amputation is a devastating injury. Thumb reconstruction can be even more challenging, when bone lengthening and tissue transfer are required for additional length and web space reconstruction for more proximal amputations. In traumatic loss, reconstructive considerations include level of amputation, functional and aesthetics requirements in both the hand and the donor site, as well as patient preference. Pollicization, osteoplastic reconstruction, and toe-to-thumb free transfer are the 3 major techniques of reconstruction. Pollicization has been the treatment of choice for reconstructing a thumb amputation in the region of the first CMC joint. Drawbacks to this technique include leaving a 4-digit hand, potentially poor cosmetics, producing a very spindly looking thumb, and reducing overall grip strength in the hand. It is also unsuitable for cases in which the ring finger has been injured, as in 1 of our patients.2Ishida O. Taniguchi Y. Sunagawa T. Suzuki O. Ochi M. Pollicization of the index finger for traumatic thumb amputation.Plast Reconstr Surg. 2006; 117: 909-914Crossref PubMed Scopus (25) Google Scholar To provide an adequate length to the thumb without compromising another finger, different toe transfers have been published.3Wei F.C. Chen H.C. Chuang C.C. Chen S.H. Microsurgical thumb reconstruction: selection of various techniques.Plast Reconstr Surg. 1994; 93: 345-351Crossref PubMed Google Scholar, 4Tsai T.M. D'Agostino L. Fang Y.S. Tien H. Compound flap from the great toe and vascularized joints from the second toe for posttraumatic thumb reconstruction at the level of the proximal metacarpal bone.Microsurgery. 2009; 29: 178-183Crossref PubMed Scopus (17) Google Scholar, 5Koshima I. Kawada S. Etoh H. Saisho H. Moriguchi T. Free combined thin wrap- around flap with a second toe proximal interphalangeal joint transfer for reconstruction of the thumb.Plast Reconstr Surg. 1995; 96: 1205-1210Crossref PubMed Scopus (19) Google Scholar Great toe transfer is a good option for amputations distal to the CMC joint, providing the most reliable functional and cosmetic outcome. The trimmed-toe modification by Wei et al6Wei F.C. Chen H.C. Chuang C.C. Noordhoff M.S. Reconstruction of the thumb with a trimmed-toe transfer technique.Plast Reconstr Surg. 1988; 82: 506-515Crossref PubMed Scopus (94) Google Scholar improved these results by thinning the toe to replicate the native thumb size and also maintaining some interphalangeal joint movement. Owing to aesthetic or cultural reasons, great toe transfer is occasionally rejected. In these cases, the second toe can be considered. However, it has an inferior cosmetic and functional outcome compared with great toe transfer, which is favored for its increased grip strength. Second toe transfer is usually not advised if the patient is a manual laborer, like our patients. Thumb reconstruction with toe transfers for proximal amputations generally requires lengthening of the metacarpal to bring it out of the palm. Adani and colleagues8Adani R. Corain M. Tarallo L. Fiacchi F. Alternative method for thumb reconstruction. Combination of 2 techniques: metacarpal lengthening and mini wraparound transfer.J Hand Surg Am. 2013; 38: 1006-1011Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar described a combination of distraction lengthening of the first metacarpal with a mini-wraparound transfer. Disadvantages to this procedure are lack of movement at the metacarpophalangeal and interphalangeal joint and prolonged treatment time, although it provides a good length for the thumb with minimal donor site morbidity. Tsai et al4Tsai T.M. D'Agostino L. Fang Y.S. Tien H. Compound flap from the great toe and vascularized joints from the second toe for posttraumatic thumb reconstruction at the level of the proximal metacarpal bone.Microsurgery. 2009; 29: 178-183Crossref PubMed Scopus (17) Google Scholar described a combined wraparound flap from the great toe and second toe proximal interphalangeal and MTP joints transfers. This technique is proposed for amputations at the CMC joint providing 2 functional joints, but it increases the donor site morbidity because 2 toes have been excised. The wraparound toe may have better cosmetic results compared with the great toe. This improvement comes at the expense of less interphalangeal joint movement. When toe transfer is used to reconstruct an amputation at this level, a prior surgery to provide sufficient soft tissue cover is needed. Traditionally a pedicled groin flap has been used,9Sabapathy S.R. Venkatramani H. Bhardwaj P. Reconstruction of the thumb amputation at the carpometacarpal joint level by groin flap and second toe transfer.Injury. 2013; 44: 370-375Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar but this technique requires a 2-stage procedure. Also, the use of a pedicled flap is rejected by some patients when they know that their hands have to be attached to the groin for 3 to 4 weeks. Second toe transfer, harvested more proximally at the metatarsal together with an overlying dorsalis pedis flap may provide the necessary reconstruction in 1 stage. However, this increases donor site morbidity and the thumb reconstruction may be suboptimal. We propose a double partial toe transfer followed by a simultaneous free tissue transfer to complete the thumb reconstruction in a single procedure. Patient 1 was resurfaced with a gracilis muscle free flap and in patient 2, we used an ALT free flap for better fit into the soft tissue defect. The gracilis muscle is a very versatile flap with reliable vascular anatomy, flexibility of the muscle to fill irregular surfaces, and a concealed donor area. A disadvantage is requirement of skin grafting to cover the muscle resulting in a potentially inferior aesthetic results compared with a fasciocutaneous flap. The ALT flap is becoming more popular for reconstruction. It has a long pedicle, adaptability as a sensate flap or flow-through with a suitable vessel diameter, and easier dissection for secondary procedures.10Misani M. Zirak C. Hau L.T. De Mey A. Boeckx W. Release of hand burn contracture: comparing the ALT perforator flap with the gracilis free flap with split skin graft.Burns. 2013; 39: 965-971Crossref PubMed Scopus (8) Google Scholar The main drawbacks are anatomical variation in the pedicle and thicker flaps in an overweight patient. In an attempt to achieve an aesthetically pleasing and functional reconstruction of the thumb with minimal donor site morbidity, we present an alternative technique using a double microsurgical transfer on a single vascular pedicle. Because the second toe is not critical during the gait, it allows for the entire MTP joint to be harvested, getting enough length for the remaining thumb reconstruction. Using it with the trimmed toe provides stronger pinch and grasp than second toe transfer alone. Finally, transposition of the second toe on top of the remaining proximal phalanx of the great toe decreases donor site morbidity, improving function and appearance of the foot.7Del Piñal F. Garcia-Bernal F.J. Regalado J. Studer A. Ayala H. Cagigal L. A technique to improve foot appearance after trimmed toe or hallux harvesting.J Hand Surg Am. 2007; 32: 409-413Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Disadvantages of our technique are the need for 2 sets of recipient vessels, longer operative time, and a more challenging technique. Download .xml (.0 MB) Help with xml files Data Profile