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1、CURRENT CONCEPTSCurrent Reconstruction Options forTraumatic Thumb LossDavid J.Graham,BPhty(hons),MBBS,*Hari Venkatramani,MBBS,MS,S.Raja Sabapathy,MBBS,MSTraumatic loss of a thumb results in notable functional impairment.Multiple reconstructive pro-cedures have been described to address these deficit
2、s.Compared with no reconstruction,any pro-cedure is of benefit.However,each of the described methods offers subtle benefits and downsidesand may be more applicable in certain situations.We present a review of current reconstructiveoptions for traumatic thumb amputation in 2016.(J Hand Surg Am.2016;4
3、1(12):1159e1169.Copyright?2016 by the American Society for Surgery of the Hand.All rights reserved.)Key words Thumb,amputation,traumatic loss,reconstruction.CME INFORMATION AND DISCLOSURESThe Journal of Hand Surgery will contain at least 2 clinically relevant articles selected by theeditor to be off
4、ered for CME in each issue.For CME credit,the participant must read thearticles in print or online and correctly answer all related questions through an onlineexamination.The questions on the test are designed to make the reader think and willoccasionally require the reader to go back and scrutinize
5、 the article for details.The JHS CME Activity fee of$15.00 includes the exam questions/answers only and does notinclude access to the JHS articles referenced.Statement of Need:This CME activity was developed by the JHS editors as a convenienteducation tool to help increase or affirm readers knowledg
6、e.The overall goal of the activityis for participants to evaluate the appropriateness of clinical data and apply it to theirpractice and the provision of patient care.Accreditation:The ASSH is accredited by the Accreditation Council for Continuing MedicalEducation to provide continuing medical educa
7、tion for physicians.AMA PRA Credit Designation:The American Society for Surgery of the Hand designates thisJournal-Based CME activity for a maximum of 1.00“AMA PRA Category 1 Credits?”.Physiciansshould claim only the credit commensurate with the extent of their participation in the activity.ASSH Dis
8、claimer:The material presented in this CME activity is made available by theASSH for educational purposes only.This material is not intended to represent the onlymethods or the best procedures appropriate for the medical situation(s)discussed,butrather it is intended to present an approach,view,stat
9、ement,or opinion of the authors thatmay be helpful,or of interest,to other practitioners.Examinees agree to participate in thismedical education activity,sponsored by the ASSH,with full knowledge and awareness thatthey waive any claim they may have against the ASSH for reliance on any informationpre
10、sented.The approval of the US Food and Drug Administration is required for proceduresand drugs that are considered experimental.Instrumentation systems discussed or reviewedduring this educational activity may not yet have received FDA approval.Provider Information can be found at http:/www.assh.org
11、/Pages/ContactUs.aspx.Technical Requirements for the Online Examination can be found at http:/jhandsurg.org/cme/home.Privacy Policy can be found at http:/www.assh.org/pages/ASSHPrivacyPolicy.aspx.ASSH Disclosure Policy:As a provider accredited by the ACCME,the ASSH must ensurebalance,independence,ob
12、jectivity,and scientific rigor in all its activities.Disclosures for this ArticleEditorsDavid T.Netscher,MD,has no relevant conflicts of interest to disclose.AuthorsAll authors of this journal-based CME activity have no relevant conflicts of interest todisclose.In the printed or PDF version of this
13、article,author affiliations can be found at thebottom of the first page.PlannersDavidT.Netscher,MD,hasnorelevantconflictsofinteresttodisclose.Theeditorialandeducationstaffinvolvedwiththisjournal-basedCMEactivityhasnorelevantconflictsofinteresttodisclose.Learning ObjectivesUpon completion of this CME
14、 activity,the learner should achieve an understanding of:?Classification of traumatic thumb defects?Potential reconstructive options at each thumb level of amputation?Osteoplastic thumb reconstruction with pedicle flaps?Nuances of toe-to-thumb transfer?Role of soft tissue free flapsDeadline:Each exa
15、mination purchased in 2016 must be completed by January 31,2017,tobe eligible for CME.A certificate will be issued upon completion of the activity.Estimatedtime to complete each JHS CME activity is up to one hour.Copyright 2016 by the American Society for Surgery of the Hand.All rights reserved.From
16、 the*Department of Hand Surgery,Sydney Hospital,Sydney,New South Wales,Australia;and the Department of Plastic Surgery,Ganga Hospital,Coimbatore,Tamil Nadu,India.Received for publication April 30,2016;accepted in revised form September 23,2016.No benefits in any form have been received or will be re
17、ceived related directly or indirectlyto the subject of this article.Corresponding author:David J.Graham,BPhty(hons),MBBS,Department of HandSurgery,Sydney Hospital,Macquarie Street,Sydney,NSW 2000,Australia;e-mail:.0363-5023/16/4112-0009$36.00/0http:/dx.doi.org/10.1016/j.jhsa.2016.09.012?2016 ASSHrPu
18、blished by Elsevier,Inc.All rights reserved.r1159Downloaded for Anonymous User(n/a)at Shanghai Jiao Tong University School of Medicine from ClinicalK by Elsevier on January 29,2023.For personal use only.No other uses without permission.Copyright 2023.Elsevier Inc.All rights reserved.THE THUMB HAS A
19、ROLE IN APPROXIMATELY40%ofhand function1;traumatic loss therefore re-sults in considerable functional impairment.Between 2007 and 2010,3,341 traumatic thumbamputations were reported in the United States.2These injuries predominantly occur in working-agedmen and most often result from machinery accid
20、ents.GOALS AND PRINCIPLES OF SURGERYA reconstructed thumb ideally would:(1)haveadequate length;(2)have a sensate,nontender tip;(3)have stability;and(4)be positioned to meet the otherdigits,with an adequate first web space.Simply put,when reconstructing a thumb,we need to have asensate stable post th
21、at is offset from the other digitsbut that still can oppose them.Littler3analyzed these attributes and believed thatalthough all of them are important,strategic posi-tioning of the thumb is the key factor to achievingoptimal function.Emphasizing this,he stated,“It isnot the full length of the thumb,
22、nor its great strengthand movement,but rather its strategic position relativeto the fingers and the integrity of the specialized ter-minal pulp tissue which determines prehensile status.”Thereconstructionshouldbecosmeticallyacceptable and have minimal donor site morbidity.ClassificationsSeveral clas
23、sification systems exist for traumaticthumb amputations.Lister4divided thumb defectsinto 4 groups:(1)acceptable length with poor softtissue coverage,(2)subtotal amputation with ques-tionable remaining length,(3)total amputation withpreservation of the basal joint,and(4)total amputa-tion with loss of
24、 the basal joint.Group 1:Amputation at or distal to the interphalangeal(IP)joint rarely results in a functional deficit and istermedacompensatedamputation.Thesecasesrequirea sensate and supple tip,which can be provided byglabrous and nonglabrous skin flaps.Glabrous flapsinclude Moberg,VY advancement
25、,neurovascularisland(Littler),and a free toe pulp transfer.Non-glabrous skin flaps include the first dorsal metacarpalartery(FDMA)eFoucher,cross-finger,dorsoulnaredorsoradial,and distant or free flaps,such as the pos-terior interosseous artery,reverse radial forearm,freegroin flaps.The Moberg flap i
26、s appropriate for volar defects ofthe distal phalanx.It measures less than 1.5 cm.However,it often requires IP joint flexion,which canbe overcome with a VY flap.aThe FMDAbflap is based on the first dorsalmetacarpal artery and can be innervated on the su-perficial radial nerve;however,it leaves a con
27、spicu-ous donor site(Figs.1e3).FIGURE 1:Group 1 defect.FIGURE 2:First dorsal metacarpal artery FDMA flap.FIGURE 3:Donor site.1160RECONSTRUCTION OPTIONS FOR THUMB LOSSJ Hand Surg Am.rVol.41,December 2016Downloaded for Anonymous User(n/a)at Shanghai Jiao Tong University School of Medicine from Clinica
28、lK by Elsevier on January 29,2023.For personal use only.No other uses without permission.Copyright 2023.Elsevier Inc.All rights reserved.Dorsoulnar(Brunelli)cordorsoradial(Moschella)d,eflaps are reverse-flow homodigital island flaps that areuseful for pulp defects and can be innervated with abranch
29、of the superficial radial nerve.Although FDMA and other regional and distantflaps do not provide glabrous skin,no clinical studiessuggest that they have worse outcome than glabrousskin flaps.Most patients function adequately after these pro-cedures.However,individuals seeking a high level ofdexterit
30、y and a more cosmetically appealing outcomemay benefit from a free toe transfer.Pial et al5ach-ieved excellent results with a partial hallux transfer foronycho-osteo-cutaneous defects and concluded thatthe best indication is dorsal oblique amputations.Group 2:Classic teaching suggests that proximala
31、mputation of the proximal phalanx inevitably resultsin reduced hand span,difficulty grasping large ob-jects,and fine pinch limitations.Parvizi et al1foundthat proximal phalanx amputations that were notreconstructed resulted in poorer M2eDisabilities ofthe Arm,Shoulder,and Hand(DASH)scores at mid-ter
32、m follow-up.The American Medical Association6considers IP joint amputations to reduce thumbfunction by 50%and metacarpophalangeal(MCP)joint amputations by 100%.Distal proximal phalanx amputations often suf-fice with web-deepening procedures.Proceduresthatproviderelativelengtheningwithouttruelengthen
33、ing have been termed“phalangization”anduse local,regional,distant pedicled or free flaps todeepen the web space.Phalangization requiresat least half of the proximal phalanx;it resultsin minimal scarring and no web contracture.FlapFIGURE 4:Group 2 thumb amputation associated with amputa-tions of the
34、index,middle,and ring fingers.FIGURE 5:Preoperative radiograph.FIGURE 6:Postoperative result of“on-top plasty.”RECONSTRUCTION OPTIONS FOR THUMB LOSS1161J Hand Surg Am.rVol.41,December 2016Downloaded for Anonymous User(n/a)at Shanghai Jiao Tong University School of Medicine from ClinicalK by Elsevier
35、 on January 29,2023.For personal use only.No other uses without permission.Copyright 2023.Elsevier Inc.All rights reserved.options include z-plasty(single-,4-,or 5-flap),dorsal rotation,and regional or free flaps(includingposterior interosseous artery,reverse radial forearm,and groin flap).Z-plastie
36、s are appropriate for deepening the web;however,when aiming for web widening,regional orfree flaps that import new skin prove beneficial.A dorsal rotation flap is indicated when the firstweb is scarred or adduction contracture is substantial.Although phalangization restores adequate func-tion,well-p
37、erformed toe transfers provide length andsensation,and are aesthetically more appealing.In an on-top plasty,adjacent digits are used toextend thumb length;in doing so,they deepen thefirst web(Figs.4e7,Video 1).Distraction osteogenesis has been used in the past,but currently alternative options are p
38、referable.Group 3:Amputations at this level result in substantialimpairment.Toe transfer is a good option for amputations distalto the carpometacarpal(CMC)joint and optimallywhere intrinsic thumb muscles are intact,providingthe most reliable cosmetic and functional outcome.The procedure requires mic
39、rosurgical expertise.A toe transfer is usually performed as a delayedprocedure to allow the patient time to appreciate theseverity of the situation,although acute transfer hasbeen described with equivalent outcomes.7When afuture toe transfer is likely,a local or regional flap isnot advisable during
40、the initial procedure because thisFIGURE 7:Postoperative radiograph.FIGURE 8:Group 3 thumb amputation.FIGURE 9:Postoperative result of great toe transfer.1162RECONSTRUCTION OPTIONS FOR THUMB LOSSJ Hand Surg Am.rVol.41,December 2016Downloaded for Anonymous User(n/a)at Shanghai Jiao Tong University Sc
41、hool of Medicine from ClinicalK by Elsevier on January 29,2023.For personal use only.No other uses without permission.Copyright 2023.Elsevier Inc.All rights reserved.may damage the critical vascular structures.A pedi-cled groin flap is an excellent option.fThe great toe flap is based on the dorsal o
42、r plantarmetatarsalarteryandisharvestedalongwiththedorsalvenous network and deep peroneal and digital nerves.Several modifications have been advocated,moti-vated by donor site morbidity and 20%discrepancy inthesizeofthethumbandthegreattoe.8Whenmultipledigits are injured,the great toe is preferred to
43、 a secondtoe because the second toe may not recreate powerfulpinch grip adequately(Figs.8e11,Videos 2,3).Trimmed toe transfer was described by Wei et al9and involves a longitudinal osteotomy to thin the toe.This has the advantage of replicating the nativethumb size and maintains some IP joint moveme
44、nt.Morrison et al10described the wraparound flap,whichusesthegreattoepulpandnailandasegmentofdistal phalanx,which is transferred with an iliac crestbone graft.This procedure results in improved cosm-esis of the donor and recipient sites.However,thereis no IP joint movement and the graft is subject t
45、oresorption.The second toe is not critical during the gait cycleand allows the entire metatarsophalangeal joint to beharvested.This may be the only toe transfer possiblefor more proximal thumb amputations.Drawbacksinclude a poorer cosmetic appearance,the tendencyto claw,and a short nail(Figs.12e14,V
46、ideo 4).Toe transfer thrombosis rates are quoted to be 10%to 15%.However,success rates are 95%to 97%whenappropriatepostoperativemonitoringandprompt return to operating room are required.11,12Sensory return can be anticipated by 4 to 6 monthsand improves for 2 years.Secondary procedurespossibly requi
47、red include tenolysis,bone or nervegrafts,web deepening,and opponensplasty.Because of anatomic or cultural reasons,occa-sionally free toe transfer is not a possibility.Alter-natively,osteoplastic reconstruction,pollicization,orlengthening may be considered.Although possible,metacarpal lengthening vi
48、a distraction osteogenesisas described by Matev13yields only approximately 3cm;although this is still beneficial,better alternativesusually exist.Other limitations include the prolongedlength of treatment,poor cosmesis,and lack ofmovement.Two thirds of the metacarpal is required,along with good skin
49、 and a compliant patient.Osteoplastic reconstruction involves a tricorticaliliac crest bonegraft(approximately 8?50?15 mm)thatisinsertedintothemetacarpalmedullarycanalandsecured,usually with Kirschner wires.This is thencovered with a pedicled flap,most often a groin flapFIGURE 10:Postoperative resul
50、t of great toe transfer.FIGURE 11:Postoperative donor site.RECONSTRUCTION OPTIONS FOR THUMB LOSS1163J Hand Surg Am.rVol.41,December 2016Downloaded for Anonymous User(n/a)at Shanghai Jiao Tong University School of Medicine from ClinicalK by Elsevier on January 29,2023.For personal use only.No other u