Long-term effects of toe transfers on the donor feet

Advances in Pediatric Toe Transfers

Microsurgery is undoubtedly the pinnacle of hand surgery. Significant advancement in recent years has stretched the indications for toe-to-hand transfer in both acquired and congenital hand defects to restore function, esthetics, and motion, with minimal morbidity to the donor site. There is no one fixed microsurgical transfer technique but a surgeon's versatility and innovation in using what one could spare because each case is unique. Esthetic refinements and reducing donor site morbidities have taken a front seat in recent years. We present a few cases to put forward the senior author's preferred techniques with this objective in mind.

Vascularized Origami Medial Femoral Condyle Flap for Finger Joint Reconstruction

SUMMARY

Total finger joint reconstruction is challenging. Vascularized toe joint transfer is currently used for reconstruction, but it is difficult to perform, fails to achieve maximal joint flexibility, and is associated with donor-site complications. As an alternative, the authors developed a vascularized medial femoral condyle flap technique, wherein the vascularized corticoperiosteum is shaped via origami, with the donor tissue folded to fit the recipient site. In this article, the authors describe the use of this method for reconstruction of interphalangeal and metacarpophalangeal joints with a reduced range of motion. The mean age of the patients (three men and four women) was 51 years (range, 36 to 68 years), and the mean follow-up period was 3 years 1 month (range, 4 months to 5 years). In the reconstructed joints, the mean range of motion; Disabilities of the Arm, Shoulder, and Hand score; and pinch strength of the unaffected side were 55 degrees (range, 24 to 90 degrees), 2.3 (range, 0 to 6), and 98% (range, 70% to 38%), respectively. No donor-site morbidities were observed. Radiography and computed tomography scans revealed joint-like grafted tissue remodeling. The study findings suggest that the origami medial femoral condyle flap is useful for functional finger joint reconstruction. The procedure requires fabrication before grafting, but tissue harvest is relatively easy.

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.

Domino Free Flap Transfer Using a Superficial Circumflex Iliac Artery Perforator Flap for the Toe Flap Donor Site

BACKGROUND

Toe-to-hand transfer is a favorable option for finger reconstruction, but donor site healing can be challenging. The superficial circumflex iliac artery perforator (SCIP) flap has yet to be used widely for toe reconstruction. The purpose of this report was to validate the efficacy of the sequential simultaneous free SCIP flap transfer for the toe flap donor site in a consecutive case series.

METHODS

The medical records of 18 consecutive patients who underwent a simultaneous SCIP flap transfer and a toe-to-hand transplant were reviewed. Free SCIP flap reconstruction was performed in a simultaneous 2-team approach. The SCIP flaps were transferred to various toe flap donor sites: a great toe wraparound flap in 9 cases, a second toe distal phalangeal flap in 4 cases, a great toe osteo-onycho-cutaneous flap in 3 cases, a twisted wraparound flap in 1 case, and a great toe hemipulp flap in 1 case.

RESULTS

The size of the SCIP flap ranged from 5 × 3 to 16 × 8 cm. A mean of the total operative time was 229.2 minutes (range, 118-441 minutes; SD, 75.8 minutes). All the SCIP and toe flaps survived completely. Minor wound dehiscence was seen in 2 cases, and the wound healed by conservative treatment. The mean follow-up period was 23.7 months (range, 7-44 months; SD, 9.7 months). No patient had gait dysfunction postoperatively.

CONCLUSIONS

A sequential SCIP flap transfer was performed simultaneously without additional time, allowing secure soft tissue coverage of the toe flap donor even with avascular tissue such as bone or tendon exposed. The sequential SCIP flap transfer can be a useful option for reconstruction of toe flap donor site, when multiple microsurgeons and microscopes are available.

Salvage Reconstruction of a Congenital Hypoplastic Thumb Due to Constriction Ring Syndrome Using a Third Toe Transfer, When the Usual Donor Sites of Index Finger, Great and Second Toes Are Not Available

Isolated third toe-to-thumb transfers have been rarely reported and none in the pediatric population. We describe a third toe-to-thumb transfer for reconstruction of a congenital hypoplastic thumb with excellent functional results and no morbidity in the donor foot.

Distal Radio-Ulnar Joint Reconstruction after failed Darrach operation using free autogenous second toe Metatarso-phalangeal joint transfer. Development of the technique and a long-term (over 25 year) follow-up

During the development of microvascular surgery in 1980-95 many new methods to overcome different traumatic disorders were studied. Previously unsolved problems could be treated using free tissue transfer. Typical problems in wrist surgery were the painful complications from ulna head resection. No sound or acceptable artificial protheses for ulna head were available. Author did study the possibilities of reversal of resected ulna head using an autogenous microvascular joint transfer. First it was done using cadaver models and evaluating the possibilities of a toe MTP-II joint in replacing the distal radio-ulnar joint. Then same principle was used in three clinical cases. All patients had suffered a poor result after ulna head resection or Darrach procedure. First two cases had complications but third case from year 1994 resulted in a good outcome. This paper introduces the development of a surgical technique for the replacement of the resected ulna head. Also, it will describe the excellent long-term result achieved in the last case with 26-year follow-up. Although today many sophisticated prosthetic replacement techniques have become developed for this purpose, this kind of autogenous reconstruction might have a place in treating similar problems in young posttraumatic patients. Also it demonstrates the potential benefit of microsurgery in a difficult wrist problem.

Novel Technique for Toe-to-Hand Transplantation: The Fourth-toe as an Alternative Option for Toe-to-Hand Transplantation for Pediatric Patients

The first toe-to-hand transplantation was done in 1898 by Nicoladoni. It was a staged procedure and the toe flap was based on a pedicle. With advancement of optical instruments and microsurgeons' skills in 1964 the first microvascular toe-to-hand transplantation on a rhesus monkey was done. The technique's development has not stopped, many authors have modified it to achieve better outcomes for both traumatic and congenital hand defects. The most commonly used toes for transplantation are first, second, and second to third toe block. Well described plantar and dorsal vascular systems for first web space vessels as well as possibility to perform successful perforator anastomosis allows us to improve toe-to-hand transplantation further. There is a paucity of studies on single fourth toe-to-hand transplantation. We performed fourth-toe transplantation for three pediatric patients (mean age, 73 mo) with congenital (n=2) and traumatic (n=1) hand defects. Common plantar digital arteries were used for blood supply to the transplanted toes. No vascular problems occurred, and all transplanted toes survived. Patients and parents are satisfied with functional and esthetic outcomes. Early podometry results show insignificant changes which should not harm the foot in the long-term. We believe the fourth-toe transplantation is a promising method to use to reconstruct congenital or traumatic absence of digits for pediatric population.

Quality of life in patients with toe-to-hand transplantation

OBJECTIVE

Toe-to-hand transplantation is a reliable procedure that replaces like-with-like in cases of a lost thumb or finger. The aim of this study is to investigate the effects of toe transplantation on patients from the perspectives of quality of life (QOL) and disability.

METHODS

Ten patients with traumatic amputation of a digit underwent reconstruction with toe transplantation. The mean age at injury was 40.2 years (range 17-59 years). Reconstructive options were 5 wrap-around flaps to 2 thumbs and 3 index fingers; 2 second-toe transplantations to 2 middle fingers, and 3 hemipulp-free flaps from the great toe to a thumb and an index finger. We hypothesized that toe transplantation would improve postoperative QOL and disability. Outcome assessments included completion of the SF-36, SAFE-Q, and DASH questionnaires before and after reconstruction. Scores on each test were calculated and intra-individual comparisons were made.

RESULTS

All scores for the eight SF-36 health domains improved, with a significant difference in Vitality from before to after surgery. In contrast, scores for all five SAFE-Q items worsened, with significant changes for the 'Pain and Pain-Related' and 'Physical Functioning and Daily Living' subscales. DASH scores improved after surgery in all cases.

CONCLUSIONS

Our results suggest that toe-to-hand transplantation for amputated finger reconstruction is a good option in terms of improved QOL. However, worsened SAFE-Q scores imply that donor site problems could be expected and must be taken into account during surgical planning.

Vascularized second metatarsophalangeal joint transfer for radial deficiency - an update

Vascularized second metatarsophalangeal joint transfer offers a possibility to reconstruct the radial support which is lacking in radial dysplasia. Our experience from 1987 to 2017 with 34 congenital radial club hand reconstructions have allowed a possibility for long-term evaluation of the method. Compared with conventional methods, second metatarsophalangeal joint transfer results in better wrist mobility and does not restrict typical ulnar growth. The balance of the wrist remains good until age 11. Thereafter, the growth of the vascularized bone graft transfer matches only partially the distal ulnar growth in adolescence, resulting in mild recurrence of radial deviation. A new option to create a two-bone forearm in selected Bayne-Klug Type III radial dysplasia cases will allow a relatively good pro-supination ability. Potentially, a proximal fibular epiphyseal transfer could be a future solution. Currently, a safe harvest of the proximal fibula at childhood remains controversial.

Vascularized Second Metatarsophalangeal Joint Transfer for Salvage of Failed Centralization in Radial Longitudinal Deficiency: Case Report

Management of recurrent radial deviation after centralization for radial longitudinal deficiency patients usually involves some form of wrist fusion. We report on a child with recurrence after centralization, where correction and successful maintenance of a good functional and cosmetic position were obtained by vascularized second metatarsophalangeal joint transfer.

Scaffolds for hand tissue engineering: the importance of surface topography

Tissue engineering is believed to have great potential for the reconstruction of the hand after trauma, congenital absence and tumours. Due to the presence of multiple distinct tissue types, which together function in a precisely orchestrated fashion, the hand counts among the most complex structures to regenerate. As yet the achievements have been limited. More recently, the focus has shifted towards scaffolds, which provide a three-dimensional framework to mimic the natural extracellular environment for specific cell types. In particular their surface structures (or topographies) have become a key research focus to enhance tissue-specific cell attachment and growth into fully functioning units. This article reviews the current understanding in hand tissue engineering before focusing on the potential for scaffold topographical features on micro- and nanometre scales to achieve better functional regeneration of individual and composite tissues.