[Application of double osteotomy and lengthening of proximal phalanx and metacarpal with Ilizarov technique for thumb defect]

Objective

To investigate the effectiveness of double osteotomy and lengthening of proximal phalanx and metacarpal with Ilizarov technique in treatment of thumb defect.

Methods

Between February 2017 and June 2019, 6 patients with traumatic thumb defects were treated with double osteotomy and lengthening of proximal phalanx and metacarpal by Ilizarov technique. There were 5 males and 1 female. The age ranged from 28 to 57 years, with an average of 41.5 years. There were 3 cases on the left side and 3 cases on the right side. All patients were admitted to the hospital in emergency department after injury, and the stump of the thumb was trimmed and sutured. The osteotomy plane was the distal part of the proximal phalanx in 4 cases and the interphalangeal joint in 2 cases. The interval between injury and osteotomy was 20-245 days (median, 34.5 days). After minimally invasive osteotomy and placement of a semi-circular external fixator, the lengthening began on the 5th day. The proximal phalanx and metacarpal were lengthened by 0.5 mm every day, once every 12 hours. The thumb of the affected side was distracted to the middle of the distal phalanx of the healthy thumb, and the fixator was removed after the bone healed.

Results

The distraction time was 14-23 days, with an average of 18.8 days. The osteotomies were healed with healing time of 91-147 days (mean, 120.2 days). The total distraction length of the proximal phalanx and metacarpal was 1.40-2.25 cm, with an average of 1.86 cm; healing index was 51.0-72.2 days/cm, with an average of 64.9 days/cm. All patients were followed up 5-12 months (mean, 8.2 months). At last follow-up, the two-point discrimination was 5.3-8.5 mm with an average of 6.98 mm. According to the evaluation standard of the upper limb part of the Chinese Medical Association, the score was 10-14, with an average of 12.5. Among them, 4 cases were excellent and 2 cases were good, with an excellent and good rate of 100%. All patients were satisfied with the function and appearance of thumb after operation. The Quick Disabilities of Arm, Shoulder, and Hand (Quick-DASH) score was 2.3-9.1, with an average of 6.1.

Conclusion

The double osteotomy and lengthening of proximal phalanx and metacarpal with Ilizarov technique is an effective method for the treatment of thumb defects.

[Surgical flap according to Littler (neurovascular island flap)]

OBJECTIVE

Defect coverage of medium-sized soft tissue defects on the ulnar side of the thumb and radial side of the index finger. By using the Littler flap, both, the lost soft tissue coverage and sensitivity, which is necessary for an exact grip to the long fingers, can be simultaneously restored.

INDICATIONS

Medium-sized soft tissue defect of the ulnar tip of the thumb, exposed bones and parts of the tendons, extensive soft tissue defects with sensory deficit.

CONTRAINDICATIONS

Limiting accompanying injuries of the hand.

SURGICAL TECHNIQUE

All-layer incision of the flap at ulnar 3rd digit with proximal exploration of the nerve and vascular bundle. Tracing the bundle to the exit from the palmar arch. After subcutaneous tunneling, shift of the flap into the defect.

POSTOPERATIVE MANAGEMENT

Immobilization of the thumb in adduction for 7 days in a dorsal plaster splint, followed by free exercise.

RESULTS

Reliable defect coverage with low donor-site morbidity and immediate restoration of sensibility in the ulnar tip of the thump. However, microsurgical dissection, especially of the nerve, is challenging.

Combination free foot flaps for digit reconstruction: A retrospective analysis of 37 cases

Combination foot flaps for digit reconstruction was previously introduced by our group as an alternative method for toe-to-hand transfer. The aim of this study was to analyze our experience with the combination foot flaps and to present the surgical refinements that were introduced. A prospective study was conducted including all combination foot flaps performed at our hospital since September 2009. Surgical refinements that were introduced during this study included island flap for repair of toenail donor site and the use of Z-plasty. The median operation duration was 6.7 hours (range 3.5-13 h). Among 74 flaps, partial necrosis occurred in three flaps (4.1%); two palmar flaps (2.7%) were bulky. Among 37 cases of reconstructed digits, contracture of the first web occurred in one case (1.4%). All the patients were able to walk well and did not complain of any pain or cold intolerance. Wound dehiscence of donor site was observed in three patients (8.1%). Toenail deformity occurred in one case (2.7%). The combination foot flap is a reliable option for digit reconstruction with minimal donor site complications.

Combined two foot flaps with iliac bone graft for reconstruction of the thumb

The purpose of this report was to retrospectively review the results of reconstruction of the thumb by use of combined two foot flaps with an iliac bone graft. From 2009 to 2014, nine patients with traumatic amputation of the thumb had their thumbs reconstructed. The two flaps were based on one pedicle. All flaps survived completely. Patients were followed for a mean of 15.6 months (range, 6-35 months). The appearance of the reconstructed thumb was comparable to a normal one, except for one thumb which required debulking. The appearance of the nail was satisfactory without deformity. The range of joint motion was satisfactory. The two point discrimination of the pulp ranged from 6 mm to >15 mm. The Michigan Hand Questionnaire outcome score was a mean of 76.2 ± 11.3 points and the Maryland foot rating score a mean of 94.8 ± 3.4 points. The combined two foot flaps with iliac bone graft might provide an option for the reconstruction of the thumb.

LEVEL OF EVIDENCE

III.