Anatomic Study of the Dorsalis Pedis Artery, First Metatarsal Artery, and Second Metatarsal Bone for Mandibular Reconstruction

The Foot as a Donor Site for Reconstruction in the Hand

The foot contains a unique collection of tissue types that can be used in the reconstruction of the hand. Numerous reconstructive options have been presented, some of which have been adopted, such as modifications to procedures that have been described in the past or even newly developed options for hand reconstruction. It is possible to reconstruct missing fingers and other hand structures using tissues taken from the foot rather than removing healthy tissue from a hand that has already been injured. This makes it possible to avoid having healthy tissue removed from an injured hand.

Radiographic Evaluation of First Tarsometatarsal Joint Arthrodesis for Hallux Valgus Deformity: Does the Fusion of the First to the Second Metatarsal Base Reduce the Radiological Recurrence Rate?

BACKGROUND

Modified Lapidus arthrodesis (MLA) is a well-established treatment option for symptomatic hallux valgus deformity (HVD). However, recurrence of the deformity remains a concern. The goal of this study was to evaluate the effect of an additional intermetatarsal fusion on the radiographic recurrence rate after first tarsometatarsal (TMT-I) arthrodesis.

METHODS

This is a retrospective evaluation of 56 feet that underwent TMT-I arthrodesis for moderate to severe HVD. Twenty-three feet received an isolated arthrodesis of the TMT-I joint (TMT-I), whereas 33 feet received an additional fusion between the base of the first and the second metatarsal bone (TMT-I/II). Various radiological parameters were determined preoperatively, 6 weeks and at a mean of 2 years postoperatively.

RESULTS

The intermetatarsal angle (IMA) and the hallux valgus angle (HVA) were significantly lowered at both follow-up evaluations in both groups. In the TMT-I/II group, the initial reduction of HVA was significantly higher (29.3° vs 21.1°). This difference disappeared by the second follow-up, leaving no significant differences between both techniques at final follow-up. Radiological recurrence rates of HVD were comparable in both groups.

CONCLUSIONS

Isolated TMT-I arthrodesis provides reliable radiological results in the correction of HVD. Whether additional fusion of the first and second metatarsal base should be routinely performed remains unclear.

LEVELS OF EVIDENCE

Level 3.

Vascularized Second Metatarsal Joint Transfer with Concomitant Orthognathic Surgery for Reconstruction of the Temporomandibular Joint: Our Pilot Experience

Background

Temporomandibular joint ankylosis-associated deformity and dysfunction is a challenge to reconstruct. Alloplastic temporomandibular joints, both stock and custom-made, are used to replace the ankylotic mass with a functional joint. Still, the cost of these alloplastic joints is so expensive that it cannot be affordable to most of our population.

Purpose

A primary objective of achieving at least 35 mm of mouth opening was planned. Secondarily we planned to achieve a functional occlusion with acceptable facial balance and symmetry.

Method

Autologous TMJ reconstruction using vascularized second metatarsal joint transfer with concomitant orthognathic surgery. The surgery aims to achieve a significant functional rehabilitation with correction of maxillomandibular deformity in a single-stage surgery.

Results

As a result of this, we present our initial experience to rehabilitate the patient with temporomandibular joint ankylosis both functionally and aesthetically by performing simultaneously joint replacement using the patient's own vascularized second metatarsal joint and concomitantly performing the orthognathic surgery. By this, we could holistically treat the patient with minimal cost and make them socially acceptable.

Conclusion

We do not propose a 2nd metatarsal vascularized flap as a substitute for a custom-made total TMJ prosthesis. Still, we suggest a viable option in a selected set of patients where TMJ prosthesis cannot be afforded or has failed with a history of multiple surgeries in the same region.

Using 320-detector row computed tomography angiography to investigate the arterial anatomy of the toe flaps on living humans

PURPOSE

Using 320-detector row computed tomography angiography (320-CTA) to investigate the arterial supply for the toe flaps, namely the anatomical characteristics of the dorsalis pedis artery (DPA), the first dorsal metatarsal artery (FDMA), and the arteries of the first toe web space (AsFTWS).

METHODS

This was a prospective study on CTA of 72 intact feet of 36 Vietnamese adults who had sequelae of thumb or metacarpal hand amputation, from June 2017 to December 2019, then preoperative CTA images were compared with surgical findings on 31 feet of 29 patients.

RESULTS

320-CTA was able to investigate the DPA, FDMA, and AsFTWS in 100% of cases. DPA was absent in 6.9% of cases. The average diameters at its origin and termination were 3.22 and 2.56 mm, respectively. For FDMA, the rates of Gilbert type I, II, and III were 52.8%, 18.1%, and 29.2%; the average diameters at its origin and termination were 1.98 and 1.67 mm, respectively. At the first toe web space, FDMA was dominant in 54.2% of cases; the first plantar metatarsal artery (FPMA) was dominant in 29.2% of cases; both arteries were equally dominant in 16.6%. The average diameter at the origin of the lateral plantar digital artery of the great toe was 1.48 mm, of the medial plantar digital artery of the second toe was 1.21 mm. Preoperative CTA images resembled the surgical findings in all cases. The survival rate of toe flaps was 100%.

CONCLUSION

The 320-CTA provided proper preoperative images in two and three dimensions, and helped surgeons to establish a preoperative surgical plan, thus increasing the success rate of toe transfer surgery.

The Innervated Distally Based First Dorsal Metatarsal Artery Flap with a Wide Pedicle for Reconstruction of a Great Toe Defect

Background

It is difficult for surgeons to reconstruct soft tissue defects of the great toe. This report aims to evaluate the utility and efficacy of innervated distally based first dorsal metatarsal artery (FDMA) flap with a wide pedicle for reconstruction of soft tissue defects of the great toe.

Methods

This is a retrospective report. Between January 2015 and December 2017, six cases of skin defect of the great toe were reconstructed with an innervated distally based FDMA flap with a wide pedicle. One case was excluded in this report because of chronic pain on the metatarsophalangeal joint due to osteoarthritis before the injury. A total of five cases were evaluated for flap survival and sensory recovery. The sensory recovery was investigated by two-point discrimination and Semmes-Weinstein monofilament tests. The average age of the selected patients was 40 years (range, 36 to 56 years), and the average size of the defect in the toe was 8.3 cm² (range, 4 to 13.8 cm²). The average follow-up period was 29.4 months (range, 18 to 38 months).

Results

All patients survived without any complications. The average two-point discrimination test value was 8.0 ± 0.89 mm (range, 7 to 9 mm), and the average value obtained from the Semmes-Weinstein monofilament test was 4.53 ± 0.33 (range, 4.17 to 4.93). The average residual pain score evaluated with a visual analog scale was 1 (range, 0 to 2). Two patients complained of stiffness in the great toe below 30° of total range of motion during the early stages after surgery, but this stiffness gradually improved after rehabilitation. The average range of motion of three patients with a remaining metatarsophalangeal joint after surgery was 80° (range, 70° to 90°). All five cases could walk regularly without any unique footwear at the final follow-up.

Conclusions

The innervated distally based FDMA flap with a wide pedicle could be a good alternative method for repair of soft tissue defects of the great toe.

Structures at Risk From an Intermetatarsal Screw for Lapidus Bunionectomy: A Cadaveric Study

The Lapidus bunionectomy is performed to treat hallux valgus. Recurrence of the deformity remains a concern. A transverse intermetatarsal screw spanning the base of the first metatarsal to the base of the second can increase stability. The neurovascular bundle is located within the proximity of this screw. In this study, we assessed the structures at risks with the use of this technique. In 10 specimens, a guide wire was placed, and a 4.0-mm cannulated screw was inserted. The neurovascular bundle was dissected and inspected for direct trauma to the neurovascular bundle, and the proximity of the screw was measured using a digital caliper. Ten cadaveric specimens were used. The dorsalis pedis artery and deep peroneal nerve were free from injury in 9 of 10 specimens. In those 9 specimens, the neurovascular bundle was located dorsal in relation to the screw. The mean distance of the screw to the neurovascular bundle was 7.1 ± 3.3 mm. The mean distance from the screw to the first tarsometatarsal joint (TMTJ) was 14.7 ± 4.3 mm. The mean distance from the screw as it entered the second metatarsal to the second TMTJ was 18.0 ± 7.2 mm. In 1 specimen, the screw was found to be traversing through the neurovascular bundle. The distance from the screw to the first TMTJ was 15.0 mm. The distance of the screw from where it entered the second metatarsal to the second TMTJ was 24.0 mm. Although the intermetatarsal screw avoided the neurovascular cases in most instances, there is some anatomic risk to the neurovascular bundle. Further study is warranted to evaluate clinical results using the intermetatarsal screw for the modified Lapidus procedure.