Gait analysis of the donor foot in microsurgical reconstruction of the thumb

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.

Long-term donor site outcome after second toe transfer for congenital hand differences

This study evaluates the long-term donor site outcomes after second toe transfers for congenital hand differences performed during childhood. In total, 25 toe transfers in 18 patients were followed up for a mean period of 17.4 years. We examined the patients clinically, radiologically and with a gait analysis system. Patient-reported outcome measures were collected. The patients were asymptomatic and there were no problematic clinical or radiological findings. Patients expressed high levels of satisfaction. The results were consistent, regardless of the resection level in the toe transfer or whether the operation was unilateral or bilateral. No postoperative complications or late reoperations on the foot were observed.Level of evidence IV.

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

Background

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.

Methods

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.

Results

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).

Conclusions

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.

Superficial Circumflex Iliac Artery Perforator Flap with Bilobed Design for the Donor Defect after Wrap-Around Flap Transfer Reconstruction

OBJECTIVE

The repair of great toe donor site defect after wrap-around flap transfer is still controversial. The bilobed superficial circumflex iliac artery perforator (SCIP) flap can improve the aesthetics of the great toe while maintaining its function. Thus, this study aimed to report our experience in the reconstruction of big toe donor site defects with the bilobed SCIP flap and describe the clinical outcomes.

METHODS

This study was a retrospective trial. From May 2017 to May 2020, 13 patients with the great toe donor site defect after wrap-around flap transfer were included in this study. The average age of the patients was 44 years (range, 23-60 years). All patients received free bilobed SCIP flaps to reconstruct the donor site defect of the great toe. Relevant clinical features were recorded preoperatively. The thickness and design of the SCIP flap and the harvesting layer of the flap were measured during the operation. The survival rate of flaps and skin grafts and the incidence of infection were recorded after operation. At follow-up, donor site complications and postoperative outcomes were evaluated.

RESULTS

In all cases, the SCIP flap covering the donor site of the great toe survived. All patients were followed up for 24-40 months (mean, 30.5 months). The average thickness of the SCIP flap was 0.38cm. All SCIP flaps were harvested from the superficial fascial layer except for three obese patients. The thin SCIP flap had a bilobed design with no further defatting procedures. Postoperatively, the great toe-nail flap donor site regained its original appearance without bloating or flap necrosis. There was a hidden linear scar in the groin donor site, which did not affect hip joint movement. All patients were satisfied with the aesthetics of the surgical site.

CONCLUSION

The SCIP flap with bilobed design for repairing the donor defect of the great toe after wrap-around flap transfer is a kind of surgical method with excellent contour, meeting the requirements of function and aesthetics.

Long-term outcomes of toe replantation: A review of ten cases

BACKGROUND

Foot injuries due to vehicular or other accidents are common. However, complete toe amputation is rare. This study explored the current protocols and clinical significance of toe replantation.

METHODS

From December 2011 to December 2018, ten patients with 13 severed toes underwent toe replantation in our hospital. Seven cases were replanted antegrade, and three cases were replanted retrograde.

RESULTS

All patients were followed for two to three years after toe replantation. One big toe underwent necrosis, while the other 12 toes survived completely. The appearance and feel of the successfully replanted toes were satisfactory, and the patients exhibited a normal gait.

CONCLUSION

Toe replantation can achieve an acceptable appearance and function of the foot and considerably reduce the psychological effects experienced by the patients. Increased clinical attention and application of toe replantation are needed.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Third Toe Pulp Reconstruction Using the Contralateral Second Toe Hemi-pulp Free Flap

A hemi-pulp flap is widely known as a flap useful for aesthetic and functional reconstruction of the fingers, and rarely used for toe reconstruction. We performed third toe pulp reconstruction using a free hemi-pulp flap harvested from the contralateral second toe to repair the tissue defect following toe replantation. An 18-year-old woman was injured with complete left third toe amputation and open fracture of the proximal phalanx of the left second toe in a traffic accident. On the same day, third toe replantation was urgently performed. After surgery, the third toe was partially taken, and had a toe pulp tissue defect due to necrosis. It was reconstructed with a free hemi-pulp flap prepared from the contralateral second toe. The flap was completely taken. Three years after surgery, the reconstructed left third toe was aesthetically favorable. Perception of the flap region was restored up to S2 without pain and there was no complication such as numbness, callus, and ulceration. In the flap donor site (right second toe), the skin graft was unnoticeable without pigmentation. Toe pulp reconstruction requires a sensory flap as low-invasive as possible with excellent sensory restoration, texture, feel, and shear property. This method is considered as one of the low-invasive, aesthetic, and functional reconstruction methods.

Aesthetic functional reconstruction of the mutilated hand: Indications and selection of reconstructive techniques

Advances in microsurgery together with improvements in reconstructive surgical techniques over recent decades have enlarged the scope of available techniques for mutilated hand reconstruction, shifting the reconstructive paradigm from restoring hand function to providing the best functional and aesthetic results with minimal donor-site morbidity. Successful reconstruction of a mutilated hand should no longer be measured only by the degree of improvement of hand function but also by a more aesthetic hand appearance as well as by improved psychological well-being. In this article, the authors present their concept of aesthetic functional reconstruction of the mutilated hand with a focus on the indications and selection of reconstructive techniques. They emphasize that in order to select the most appropriate technique, providing the best functional and aesthetic outcomes with minimal donor-site morbidity for each individual patient, it is imperative for the reconstructive hand surgeon to possess perfect mastery of all available surgical techniques, thorough understanding of functional and aesthetic requirements and accurate appreciation of multidimensional reconstruction of a given defect of the hand. They have concluded that in precisely indicated cases, successful replantation of an amputated hand or digits remains the best reconstructive procedure designed to obtain a more functional and more normal-appearing hand, whereas, toe-to-hand transplantation, in cases of failed or impossible digit replantation, provides better results than any other digit reconstruction techniques aimed at achieving functioning digits with good appearance. Although skin graft and various distant pedicled flaps and free flaps may be valid options for coverage of some soft tissue defects of the hand, reverse flow forearm flaps, especially those based on the secondary arteries of the forearm, are often the best-suited reconstructive options for like-with-like hand reconstruction. They can provide the best matching of color, texture, soft-tissue volume, donor-recipient tissue interface and fulfill all the aesthetic and functional reconstruction requirements of moderate-sized or even large soft tissue defects of the hand, with acceptable donor site morbidity.

Gait Improvement and Ulcer Prevention With Second-to-Great Toe Transposition at the Donor Site: A Case Report

A young male patient, who sustained a severe burn injury 6 years ago, received amputation of left hand at the level of metacarpal shaft of the thumb and base of proximal phalanxes of the rest of the fingers. Staged operations, including combined second- and third-toe transfer from the right foot to middle and ring fingers of the left hand, and harvest of great toe from the left foot for reconstruction of left thumb, were successively executed. Unfortunately, callus and ulcer were found at the plantar area of first metatarsophalangeal joint of left donor foot in the following 2 years, which caused troublesome disturbance during ambulation. We hereby present how second toe transposition can decrease the donor foot pain and prevent the recurrence of plantar ulcer after 21 months of follow-up.

[Secondary digit reconstruction of mutilated hand]

Traumatic digit amputation generates functional, aesthetic and psychological disabilities. Such post-traumatic consequences call for a rigorous therapeutic approach, aiming at an early secondary surgical procedure - which is ideally to be performed before the patients psychologically recover from their initial trauma. The therapeutic principle consists in improving the global function of the hand, basically aiming at re-creating a quality pollici-digital pinch, ideally thin, stable, sensitive, strong, mobile enough, but also, when possible, at improving the aesthetic aspect of the hand. The therapeutic arsenal includes not only surgical processes using local ressources in order to improve the allocation of the remaining digital capital such as phalangisation, elongating techniques, proximal amputation, digital translocation and redistribution but also remote processes - such as osteoplastic and toe-to-hand transfer techniques. The authors expose their approach and indications of secondary digit reconstruction procedures in mutilated hand. They conclude that a thorough knowledge and mastery of the vast available therapeutic arsenal, a fine and profound analysis of the benefits and downsides of each available surgical technique, a comprehensive acknowledgement of the patient's personal information such as age, gender, profession, dominant hand, status of the mutilated hand, physical and psychological health as well as patient's desire are all necessary in order to define the best therapeutic strategy for each particular case.

Extreme Thumb Losses: Reconstructive Strategies

BACKGROUND

Historically, complex amputations of the thumb have been managed in two stages and often require additional soft-tissue and tendon transfer for successful outcomes. This article provides several novel strategies to address these problems in a single stage using existing muscles, immediate free tissue transfer, and toe transfer.

METHODS

From a personal experience of 482 toe transfers, 24 cases were performed to reconstruct extreme thumb losses. All thumbs were reconstructed in one stage. In only one case, the thumb was reconstructed with a second toe transfer; the remainder had a great toe (or a part of it) used for reconstruction. Suture, advancement, or tendon transfers were performed in all to restore intrinsic muscle function. In 19 cases, the web needed to be resurfaced with free (n = 18) or local (n = 1) flaps.

RESULTS

All toes and flaps survived. Three patients required a secondary adductorplasty. Six of the seven patients with a metacarpal hand were able to perform tripod pinch. The rest had an average Kapandji opposition score of 7.5. Patients rated their functional and cosmetic result with a visual analogue scale score (ranging from 0 to 10) of 8.5 and 8.4, respectively.

CONCLUSIONS

In proximal thumb amputations, the surgeon should pay attention not only to the obvious thumb loss but also to the first web and the thenar muscles. The author recommends abandoning the standard approach of a pedicled groin flap followed by a toe. Otherwise, the thenar muscles become useless, the first metacarpal contracts, and the need for tendon transfers skyrockets. Further studies are required to compare the outcomes of these results to those of more classic transfers.

CLINICAL QUESTION/LEVEL OF EVIDECE

Therapeutic, IV.

Reconstruction of digit planer injuries using component transfer of double second toes: A case report

The purpose of this report is to show that customized component second-toe transfers may improve functional and aesthetic outcomes following bone, soft tissue, and joint destruction of traumatically injured digits. A 22-year-old male sustained a planer injury resulting in loss of the distal volar soft tissues of the middle, ring, and small fingers, along with variable destruction of middle phalanges and distal interphalangeal joints. Simultaneous vascularized second-toe transfers were performed with customized joint and pulp reconstruction of middle and small fingers. The ring finger was salvaged using non-vascularized autologous bone graft and acellular dermal matrix. The patient had an uncomplicated postoperative course. Five-year strength, sensory and patient reported outcomes represent overall satisfactory results. Strength testing revealed the injured hand to perform within 90% strength of the uninjured side. Sensory outcomes showed present but diminished sensory perception in each of the injured digits. The patient's upper extremity function, physical health, quality of life, and foot health were overall acceptable, and he returned to using his hand for typing, writing, weight-lifting, and woodworking.

Thumb Amputations Treated With Osseointegrated Percutaneous Prostheses With Up to 25 Years of Follow-up

Introduction

Implantation of an osseointegrated percutaneous prosthesis provides a reconstruction alternative for thumb amputation without sacrificing donor tissues.

Methods

Thirteen thumb amputees received osseointegrated prostheses (1990 to 2014). The treatments were started with custom-designed implants. Since 2005, standardized implant components and structured rehabilitation protocols were introduced. The median follow-up period was 9.5 years.

Results

Six patients were lost to follow-up. Seven patients (including all six after the introduction of the standardized protocol) had good osseoperception, grip strength (Jamar) was 28.3 kg on the operated side versus 40.4 kg in the unaffected hand (70%), and key grip strength was 6 versus 9.1 kg. Hand function was 94% of the normal hand. The most common complications were mechanical failures necessitating changes of components (eight times in three patients) and superficial infections (seven times in five patients). Five patients had no complications. The refined implant design and new standardized treatment protocol achieved a 100% cumulative success rate with 9.5 years of follow-up so far.

Discussion

Treatment of thumb amputees using bone-anchored percutaneous prostheses seems to be a safe, durable method with excellent short- and medium-long follow-up results. Severe adverse events are few except for implant loosening which occurred only in the early custom-designed group.

Microsurgical thumb repair and reconstruction

In this article, we review microsurgical reconstructive techniques available to treat thumb amputation at different levels based on our experience. We reference techniques used by other surgeons and identify the most suitable technique for different clinical situations. Indications and techniques for microsurgical partial or composite transfer of the great or second toe for thumb reconstruction are summarized. Different microsurgical transfer techniques suggest a great freedom of surgical choices. However, the choices are considerably restricted if all functional and cosmetic requirements are to be met. We recommend individualized surgical design and reconstruction because each case of thumb amputation is unique.

[Repair of the donor defect after wrap-around flap transfer with free thinned innervated anterolateral thigh perforator flap]

Objective

To explore the feasibility of harvesting free thinned innervated anterolateral thigh (ALT) perforator flap for repairing the donor defect after wrap-around flap transfer.

Methods

Between May 2011 and December 2013, free thinned innervated ALT perforator flap was used to repair the donor defects after wrap-around flap transfer in 9 patients. There were 8 males and 1 female, with a mean age of 31.2 years (range, 19-42 years). The interval time between injury and admission was 3-12 hours (mean, 6.5 hours). Injury causes included machine crush injury (4 cases), traffic accident injury (3 cases), and twisting injury (2 cases). The wrap-around flaps were transferred to reconstruct thumb defects. And the size of donor site defect ranged from 3 cm×2 cm to 8 cm×5 cm. A branch of the lateral femoral cutaneous nerve was carried to make innervated ALT perforator flap for donor site repair. The size of innervated ALT perforator flap ranged from 3.0 cm×2.0 cm to 8.5 cm×5.0 cm. The thickness of innervated ALT perforator flap before defatting ranged from 2.0 to 4.5 cm (mean, 3.2 cm); the thickness after defatting ranged from 0.4 to 0.6 cm (mean, 0.5 cm). The defect at the anterolateral thigh was primarily closed in all cases.

Results

All reconstructed thumbs and ALT perforator flaps survived. All patients were followed up 6-30 months (mean, 15.8 months). The ALT perforator flaps had good appearance and color, with no further flap revision or defatting procedures. The static two-point discrimination was 8-15 mm (mean, 10.5 mm). All patients could walk and run normally without postoperative skin erosions or ulcerations.

Conclusion

The free thinned innervated ALT perforator flap is pliable and thin. It is suitable for repairing the donor site defects after wrap-around flap transfer for thumb reconstruction.

Long-Term Follow-Up on the Donor Foot After Thumb Reconstruction Using Big Toe Wrap-Around Flap in Two Different Operation Methods

The function of the donor foot has been affected after using big toe wrap-around flap for thumb reconstruction. A modified operation method has been developed to reduce the adverse effect on the donor foot. The current study compared the long-term effect of the classic and the modified operation methods on the donor foot. Gait analysis was carried out, including how the patient walked, the walking speed and walking distance, and how the patient jumped and ran. Plantar pressure was measured while the patient was standing and moving. A total of 45 patients who received the 2 different operation methods were included. The follow-up time was 4-10 years with a mean of 6.5 years. Various degrees of complications occurred for the 21 patients who received the classic operation method. For these patients, plantar pressure of the donor foot was obviously different comparing with the healthy unaffected foot while the patient was standing or walking. For the 24 patients who received the modified operation method, no obvious complications were observed and the plantar pressure of the donor foot and the healthy unaffected foot was similar while the patient was standing or walking. In conclusion, both the classic and the modified operation methods have affected the function of the donor foot after using the big toe wrap-around flap for thumb reconstruction. However, the donor foot was less affected when the modified operation method was used.

Aesthetic Multiple-Toe Reconstruction With Combined Iliac Bone Graft and Wraparound Free Anterolateral Thigh Flap-A Case Report and Literature Review

Compared with upper extremity injuries, toe amputations and their replantations are rare because of the difficulty of their relatively thinner soft tissue envelope. Consequently, fewer reconstructive options are available for toes and they are rarely reported in the literature. In this study, we reported a case of right third to fifth toe amputations and their subsequent reconstruction with iliac bone grafts and a free anterolateral thigh flap. After serial debulking and division procedures, 3 toes were divided successfully. Ten months after the initial operation, the patient regained pain-free functional ambulation despite some bone resorption noted on follow-up radiographs. The patient showed high satisfaction on her new toes in terms of aesthetical and functional outcomes. She was able to stand for over 30 minutes without pain. At the 2-year follow-up, the Foot Function Index was 18.3%. Although toe reconstruction is frequently considered unnecessary because of its relative high demand of surgical techniques and little gain on gait; nonetheless, in selected cases, toe reconstruction may still be beneficial if the metatarsophalangeal joints were intact and there is a strong individual desire for aesthetical restoration.

The Rotterdam Foot Classification: A Classification System for Medial Polydactyly of the Foot

BACKGROUND

Polydactyly at the medial side of the foot ("medial polydactyly" of the foot) is a rare and diverse congenital anomaly. In order to plan and evaluate surgical treatment, the classification of medial polydactyly is useful. The aim of our study was to develop a reliable and valid classification system for medial polydactyly of the foot that is more useful than previous systems for preoperative evaluation and surgical planning.

METHODS

A review of the literature and the clinical experience of a single experienced surgeon were used to determine classification categories. We identified all patients with medial polydactyly who had preoperative radiographs and clinical photographs and were treated at our hospital between 1993 and 2014. All affected feet were assessed according to our proposed classification system, the Rotterdam foot classification. The intrarater and interrater reliability among 5 observers who evaluated 30 feet were assessed with use of the Cohen kappa (κ) statistic.

RESULTS

We developed a classification system that describes duplication type, syndactyly, the presence of a hypoplastic ray, and deviation of the hallux. Seventy-three feet were classified according to the system. Seven duplication types were distinguished. Complete metatarsal duplication was most frequently seen (in 29%). Twelve feet showed a broad hallux without external expression of duplication. Syndactyly between medial and lateral (duplicate) halluces was present in 30 feet; between the lateral hallux and second toe, in 13 feet; and between both duplicated halluces and the lateral hallux and second toe, in 21 feet. A hypoplastic ray was seen in 75% of the feet. Intrarater agreement for duplication, hypoplastic rays, syndactyly, and deviation were, respectively, κ = 0.79, 0.75, 0.59, and 0.78. Interrater agreement for duplication, hypoplastic rays, syndactyly, and deviation were, respectively, κ = 0.72, 0.54, 0.48, and 0.64.

CONCLUSIONS

The proposed classification system contains 4 categories of anatomic features of the foot. Classification of all categories shows moderate to good reliability. Use of the Rotterdam classification in evaluating medial polydactyly improves type-specific description, which may, in the future, enhance the evaluation of surgical treatment.

CLINICAL RELEVANCE

The Rotterdam foot classification system is a reliable and easy-to-use system that we believe will improve communication between clinicians and researchers and facilitate the evaluation of treatment results in medial polydactyly of the foot.

EFFECT OF SECOND TOE-TO-HAND TRANSFER ON THE PLANTAR PRESSURE DISTRIBUTION OF THE DONOR FOOT

Objective:

To investigate the effect of second toe-to-hand transfer on the plantar pressure distribution of the donor foot.

Methods:

Twelve normal fresh-frozen cadaveric foot specimens were subjected to an axial load of 600 N. An F-Scan plantar pressure analysis system was used to measure the forefoot plantar pressure. The testing was performed under the conditions of intact second toe, second toe removal with the second metatarsal head reserved, and second toe removal in combination with the distal one-third of the second metatarsal, respectively.

Results:

The peak pressure of the second metatarsal head was greater than other four forefoot plantar regions. There was no statistically significant change in the forefoot plantar pressure distribution after the second toe was removed (p > 0.05). When the second toe and the distal one-third of the second metatarsal were removed, the forefoot plantar pressure distribution changed significantly (p < 0.05).

Conclusions:

An intact second metatarsal is essential for the normal distribution of plantar pressure. Removal of the second toe with the second metatarsal head reserved had little influence on the plantar pressure distribution of the donor foot. Removal of the second toe and distal one-third of the second metatarsal resulted in abnormal plantar pressure distribution. Level of Evidence II, Experimental Study.

Long-term effects of toe transfers on the donor feet

The purpose of this study was to assess the long-term consequences to the donor site of microvascular transfer of one or two toes. This was achieved retrospectively by patient-reported, clinician-based and functional testing. Weight-bearing radiographs were taken of both feet. Seventy-four patients (80 feet, 84 transferred toes) participated in this study. After a median of 16 years follow-up, most patients reported no or only minor complaints concerning the donor site. Cold intolerance and pain during exertion were the most commonly reported complaints. According to the two functional scores used, 92% of patients reported no or minor complaint and 83% of patients received a good result at the donor feet. Maintaining first ray alignment and avoiding early postoperative complications predicted a better outcome. Even though donor site ramifications should be expected after microvascular transfer of toes, patient satisfaction remains high.

Digital ray transposition for correction of late-stage post toe-to-hand transfer forefoot deformity

A patient with a painful, severe crossover third toe presented approximately 30 years after a second toe-to-hand transfer. He was successfully treated with multiple digital ray transposition. This procedure can realign the lesser toe, close the toe web, and eliminate the need for lifelong use of a toe filler.

A systematic review of outcomes of toe-to-thumb transfers for isolated traumatic thumb amputation

BACKGROUND

Toe-to-thumb transfer is an established procedure for reconstruction of traumatic thumb amputations. The four types of toe-to-thumb transfers are the second toe, the great toe, the wrap-around great toe and the trimmed great toe transfers. The purpose of this study is to conduct a systematic review of the literature to compare outcomes amongst different methods of toe-to-thumb transfers.

METHODS

A literature search using 'toe-to-thumb transfer' combined with 'thumb injury' and 'thumb reconstruction' as keywords and limited to humans and the English language identified 633 studies. Studies were included in the review if they: (1) present primary data, (2) report three or more toe-to-thumb transfers for isolated complete traumatic thumb amputation between the metacarpophalangeal joint and the interphalangeal joint (both excluded) and (3) present functional outcome data.

RESULTS

Twenty-five studies representing 450 toe-to-thumb transfers met the inclusion criteria. They included 101 second toe transfers, 196 great toe transfers, 122 wrap-around transfers and 31 trimmed toe transfers. The mean survival rate was 96.4%. No statistically significant differences could be detected between the four transfers with regards to survival, arc of motion, total active motion, grip and pinch strength and static two-point discrimination.

CONCLUSIONS

All four types of toe transfer procedures have predictably high survival rates and good patient satisfaction scores. The current data are inadequate to make any comments with regards to donor site morbidity. Till such data are available, an evidence-based recommendation for the superiority of a specific type of toe-to-thumb transfer cannot be made.

Donor foot morbidity following modified wraparound flap for thumb reconstruction: a follow-up of 69 cases

PURPOSE

To evaluate donor foot morbidity after thumb reconstruction using a modified wraparound flap.

METHODS

We observed patients who accepted thumb reconstruction with the modified wraparound flap between January 2001 and December 2009. We examined and evaluated the reconstructed thumb and donor foot. Donor morbidity was assessed on both a subjective and an objective basis using the Foot Function Index-verbal rating scales (FFI-5pt), the American Orthopaedic Foot and Ankle Society for Hallux Metatarsophalangeal-Interphalangeal (MTP-IP) scale, and gait analysis and dynamic pedodynographic measurements.

RESULTS

We reviewed 69 patients; the follow-up period ranged from 6 months to 5 years, with an average of 26 months. The reconstructed thumbs had good aesthetic appearance, and static 2-point discrimination averaged 9.4 ± 2.7 mm. Full length or most of the length of the donor toes was preserved in 67 patients. The retained plantar strip was significantly enlarged from an average of 14.5 ± 1.4 mm measured at surgery to 27.8 ± 4.7 mm measured at last follow-up (p < .05), and its 2-point discrimination was 9.1 ± 2.3 mm. A total of 34 patients were available for FFI-5pt and Hallux MTP-IP scale evaluation. The FFI-5pt total score was 3.1 ± 2.7 and the total Hallux MTP-IP score was 87.9 ± 7.1. Gait analysis and dynamic pedodynographic measurements were available in 20 patients. All 5 biomechanical parameters (timing, trajectory, symmetry, average peak force, and peak pressure between donor foot and the contralateral foot) had no significant difference.

CONCLUSIONS

The function of the donor foot after a modified wraparound flap for thumb reconstruction was well preserved, the degree of pain and disability in the donor foot was mild, and foot function in gait was not disturbed. Although a certain degree of restriction in interphalangeal joint motion occurred, this was nearly negligible and did not deter return to normal daily living activity, work, and recreation.

The role of the great toe in balance performance

The objective of this study was to evaluate great toe function in maintaining static and dynamic balance. Correlation among great toe length, body height, and balance performance parameters were also investigated. Thirty females (aged 22.1 +/- 1.9 years) were tested in two great toe conditions: unconstrained and constrained. Balance testing was done in the following order: (1) static balance, single-leg stance with right or left foot, eyes open or closed; (2) static balance, stance with both feet, eyes open or closed; (3) dynamic balance, left/right or forward/backward, rhythmic weight shifting; and (4) dynamic balance, target reaching test, eight targets within 90% limit of stability. Significant differences were found in sway velocity between the two toe conditions with eyes open or closed in single-leg stance (p < 0.05). No difference was found between the two conditions while standing with both feet. For rhythmic weight shifting, significant differences in sway velocity were found in toe conditions and in weight-shifting directions (p < 0.05). As to target reaching, significance was only noted in directional control scores. Great toe length was correlated with subject's height (r = 0.553, p < 0.05). Our results indicate that constraining the great toe deteriorated the subjects' single-leg stance performance and worsened the directional control ability during forward/backward weight shifting. The importance of the great toe in balance may be taken into account in toe amputation or transfer in the future.

Immediate reconstruction of a nonreplantable thumb amputation by great toe transfer

BACKGROUND

When replantation of an avulsed/amputated thumb is not feasible, toe-to-hand transfer may be considered as a reconstructive option in appropriately chosen patients. Although selection criteria are purposefully restrictive, immediate one-stage transfer, as opposed to a delayed procedure, provides many advantages. Primary reconstruction reduces hospitalization and operative and recovery time. It also may expedite return of function and allow patients to return to work sooner. The ability of the patient to undergo extensive microvascular reconstruction at the time of injury, the psychological preparation required, and the need to understand potential risks are important factors to consider.

METHODS

In the past 5 years, six patients suffering thumb amputation underwent immediate great toe-to-hand transfer. The overall results of these thumb reconstructions were evaluated retrospectively with regard to function, outcome, length of stay, complications (e.g., infection, contracture, reexploration), and time to return to work/normal activity. The authors calculated objective and subjective scores with which to quantify patient satisfaction and clinical success.

RESULTS

All of the authors' patients were laborers who suffered work-related avulsion-amputations. No complications were reported during initial hospitalization, lasting an average of 12 days. Donor-site morbidity was minimal.

CONCLUSIONS

The data suggest that thumb reconstruction using great toe transfer can be safely and reliably performed during the initial presentation in selected patients. The economic and therapeutic advantages should be weighed against the risks associated with this approach when evaluating thumb avulsion-amputations.

Transfer of the second to the first metatarsal ray in a case of lawn mower injury: a case report

The medial longitudinal arch of the foot plays a major role for a physiologic transfer of the load from the heel to the forefoot during walking and running. Traumatic amputation that involve either the great toe or the whole first metatarsal bone can lead to collapse of the medial longitudinal arch, overload of the metatarsal heads, and painful callus formation. If replant of the amputated part is not possible or has failed, it is advisable to reconstruct the medial longitudinal arch in order to re-establish a functional transfer of the load in the foot. We present a case of a young lady who suffered from traumatic amputation at the distal third of the first metatarsal. Replantation failed due to the severity of the initial injury. Despite a good coverage of the defect with a lateral arm flap, the patient developed a painful plantar callus underneath the amputated stump. The adjacent second metatarsal ray was then raised as a pedicled flap including bone and soft tissues and transferred to the first ray in order to reconstruct a physiologic medial longitudinal arch. The patient had excellent functional results with no recurrence of the callus.

A technique to improve foot appearance after trimmed toe or hallux harvesting

We describe a technique to improve the appearance of the donor site after hallux harvesting. The surgery has been used in 6 consecutive patients having a trimmed-toe-type transfer. Instead of the classic stump closure advised by Wei, the following steps were performed on the donor site: (1) removal en bloc of the second metatarsal and transposition of the second toe on top of the proximal phalanx of the hallux, (2) interposition of a tibial (medial) glabrous flap from the tibial aspect of the hallux onto the tibial side of the second toe to increase its size, and (3) eponichial flap to increase the nail show on the second toe. Fixation of the toe was achieved with K-wires and cerclage wire. Crossed K-wires stabilized the first to the third metatarsals for 4 to 6 weeks. Ambulation with a stiff sole was allowed a few days after surgery. The main advantage of this technique is the improved donor site appearance. As a bonus, the amount of skin that can be harvested with the trimmed toe is slightly increased. The main drawback is that the number of toes is reduced to 4.

The aesthetic mini wrap-around technique for thumb reconstruction

In the past 12 years, 16 thumb defects at, or distal to, the interphalangeal joint were reconstructed using a great toe mini wrap-around flap. A flap including the entire nail and most of the distal phalanx of the great toe was used. Fifteen of the grafts survived. The sensory recovery of the reconstructed thumb was good as assessed by 2-point discrimination test with an average of 10 mm (range 5-15), and there were no complaints of cold intolerance. This technique results in good cosmetic appearance, and all patients were pleased with the cosmetic aspect of the thumb and there was no significant morbidity at the great toe donor site. The final decision to reconstruct a distal thumb amputation is influenced by gender, job, and age of the patients. The great toe mini wrap-around flap is an excellent reconstruction technique in selected patients.

Painful foot neuromas after toe-to-thumb transfer

Reconstruction of the thumb by transfer of a toe has evolved technically to the point that this complex procedure can result in a mobile, sensate, and aesthetically pleasing digit that contributes to an almost-normally functioning hand. Donor site deformity is well recognized, primarily as it relates to the appearance of the foot after transfer of the hallux to the thumb position and stiffness of the remaining portions of the big toe. The present report describes donor site disability related to painful neuromas of the superficial and deep peroneal nerves and the common plantar digital nerve to the first webspace. Salvage of the disabled donor foot is possible by applying techniques used to treat painful neuromas of the upper extremity, neuroma resection, and muscle implantation. The specific techniques used in treating this painful foot donor site after toe-to-thumb transfer are described.

Composite osteocutaneous groin flap combined with neurovascular island flap for thumb reconstruction

Three amputated thumbs were reconstructed with a composite osteocutaneous groin flap and a neurovascular island flap. The average age at the time of surgery was 28 (range 25-35) years. The level of the amputation was distal to metacarpophalangeal joint in two cases and proximal in one case. The injury mechanism was avulsion in all cases. The postoperative follow-up periods ranged from 27 to 30 months. There were no cases of skin necrosis, bone resorption or infection. Radiographs and three-phase bone scans showed union of the iliac bone block and the stump without any resorption in all three patients. This surgical procedure is reliable and simple and the functional results are satisfying. We reserve this technique for the treatment of thumb amputations which cannot be replanted, particularly as it does not result in bone resorption.

Should the amputations of the great toe be replanted?

Seventeen great toes, amputated at the distal phalangeal to the level of the MTP joint, were replanted between 1990 and 1998, at Izmir Hand and Microsurgery Hospital. Replantation in five out of six complete amputations, and seven out of eleven incomplete amputations were successful, and the overall survival rate was 76.4%. In failed replantations, the base of the proximal phalanx of the great toe was preserved during closing of the stump. Nine of 17 patients were available for review in the follow-up period of mean 3.5 years (range 1-6.5 years). Clinical and biomechanical evaluations of the operated feet were carried out in five patients who had replanted great toe, and in four patients who had amputated one. The uninjured sides were used as control group. The patients in the two groups had no significant subjective symptoms, nearly normal ROM of the MTP joint and protective sensation was achieved in the replanted great toes. With the numbers available, while radiographical parameters of the involved and the control sides demonstrated no significant differences in either groups, pedographical studies revealed consistent changes in weight-bearing distribution of the feet with amputated great toes. Although the great toe amputation causes no disturbance in gait, it alters the load distribution of the foot.

An outcome study of thumb reconstruction using microvascular toe transfer

The purpose of this study was to evaluate outcomes following microvascular toe to thumb transfer in a cohort study using the Michigan Hand Outcomes Questionnaire, the 36-item Short-Form Health Survey, the Lower Limb Function Questionnaire, and standardized hand function tests. Twenty-one patients who had unilateral, isolated thumb amputations at the metacarpophalangeal joints were studied: 16 patients had toe transfer and 5 patients did not have reconstruction. The mean follow-up period was 7.2 years (range, 3-13 years). Toe transfer patients showed statistically significantly better overall hand function (effect size = 1.4), ADL (effect size = 3.4), work performance (effect size = 2.1), aesthetics (effect size = 1.9), and satisfaction (effect size = 1.1). Functional testing showed that strength and dexterity of the toe transfer hands were comparable to the opposite normal hands. Foot donor site morbidity was minimal. No significant difference was found in the mean Lower Limb Function Questionnaire scores between the toe transfer patients (1.4) and the amputation patients who did not undergo reconstruction (1.6). The results of our study showed that patients with toe transfer have better hand function than patients with thumb amputations at the level of the metacarpophalangeal joints.

Tendon arthroplasty of the first metatarsophalangeal joint in hallux rigidus: preliminary communication

A biological arthroplastic interposition is described for hallux rigidus, in which the rolled plantaris tendon is positioned at the base of the first phalanx. Eleven patients, for a total of 12 feet, underwent surgery using this technique. The average follow-up was 21 months. In all patients, pain and supination gait disappeared. The average metatarsal motion increased 44 degrees in dorsiflexion. The tendon packet seems to be a good biological spacer, because it adapts and models itself to the new joint function.