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1、Reconstruction of combined thumbamputation at the metacarpal base level andindex amputation at the metacarpal levelwith pollicization and bilateral double toecomposite transferZhenglin Chia,1,Da Jiang Songb,1,Lin Tianc,Fu Hua Hud,Xiao Fang Shene,*,Harvey Chimf,*aDepartment of Orthopedic Surgery,The
2、Second Affiliated Hospital of Wenzhou Medical College,Wenzhou,ChinabDepartment of Oncology Plastic Surgery,Hunan Provincial Cancer Hospital,Xiang Ya Medical School ofCentral South University,Changsha,ChinacDepartment of Hand Surgery,Great Wall Hospital,Chongqing,ChinadDepartment of Hand Surgery,Zhou
3、shan Guangan Orthopedic Hospital,Zhoushan,ChinaeDepartment of Hand Surgery,Wuxi 9th Peoples Hospital,Wuxi,ChinafDivision of Plastic and Reconstructive Surgery,University of Florida,Gainesville,FL,USAReceived 26 December 2016;accepted 10 May 2017KEYWORDSToe to thumbtransfer;Thumb amputation;Toe to fi
4、nger transfer;Toe wrap-aroundflap;PollicizationSummaryBackground:This study aimed to describe the technique and report our experi-ence with the reconstruction of combined proximal thumb amputations at the metacarpal baselevel and index finger amputation at the metacarpal level with pollicization and
5、 bilateral dou-ble toe composite transfer.Methods:The technique consists of pollicization of the remnant index ray.Then a contralat-eral composite medial great toe pulp and vascularized second toe proximal interphalangealjoint flap are harvested to reconstruct the metacarpophalangeal joint of the th
6、umb.Subse-quently,an ipsilateral composite great toe wrap-around and second toe proximal interphalan-geal joint flap are harvested to reconstruct the thumb interphalangeal joint and the distalthumb.A neurotized superthin anterolateral thigh flap is used to reconstruct the ipsilateraltoe defect,while
7、 the bone defects of the bilateral second toes are reconstructed with*Corresponding author.Division of Plastic and Reconstructive Surgery,University of Florida College of Medicine,1600 SW Archer Rd,POBox 100138,Gainesville,FL 32610,USA.Fax:1 352 273 8639.*Corresponding author.Department of Hand Surg
8、ery,Wuxi 9th Peoples Hospital,Wuxi,Jiangsu 214062,China.Fax:86 051085873955.E-mail addresses:(X.F.Shen),(H.Chim).1Zhenglin Chi,MD and Da Jiang Song,MD are co-first authors.http:/dx.doi.org/10.1016/j.bjps.2017.05.0321748-6815/2017 British Association of Plastic,Reconstructive and Aesthetic Surgeons.P
9、ublished by Elsevier Ltd.All rights reserved.Journal of Plastic,Reconstructive&Aesthetic Surgery(2017)70,1009e1016corticocancellous iliac crest bone grafts.Between 2010 and 2014,eight patients underwentreconstruction.Four patients could be recalled for follow-up,with a mean duration of 22months.Resu
10、lts:All flaps survived.The contour and length of the reconstructed thumbs was similar tothe contralateral one.The mean Michigan hand outcomes questionnaire score was 80.5.Themean disabilities of the arm,shoulder and hand score was 7.5.The mean foot and ankledisability index score was 94.2.Conclusion
11、s:Reconstruction of thumb amputations at the metacarpal base level with pollici-zation and double toe composite transfer results in excellent contour and functional outcome,with a natural-appearing thumb.In addition,all toes are preserved.Level of evidence:Therapeutic,Level IV 2017 British Associati
12、on of Plastic,Reconstructive and Aesthetic Surgeons.Published by Else-vier Ltd.All rights reserved.IntroductionReconstructionofproximalthumbamputationsisextremely challenging.Different designs of toe to thumbtransfers have been described,inclusive of trimmed toe,wrap-around toe,second toe,and other
13、variations.1e3However,for thumb amputations proximal to the meta-carpophalangeal(MCP)joint,none of these work very well.The problem then to be addressed is of length and softtissue coverage.Several approaches have been used.Theseinclude a preliminary groin flap for coverage followed bytransfer of th
14、e second toe with the metatarsal for length.4Another option is metacarpal distraction lengthening fol-lowed by toe transfer.5Osteoplastic reconstruction of thethumb ray with a vascularized or nonvascularized iliac crestbone graft sometimes followed by secondary toe transfer isanother effective optio
15、n for restoration of length andfunction.6,7Another option for osteoplastic reconstructionis a reverse flow radial forearm osteocutaneous flap.8Pol-licization of course is another option,9e11but this requiresthat the index finger is intact and uninjured.A limitation of all these techniques is the som
16、etimeslimited function obtained and altered appearance of thereconstructed thumb,which may not resemble a naturalthumb.In Lins series of 24 thumb amputations proximal tothe MCP joint reconstructed with osteoplastic surgery,forexample,only 54%achieved opposition.6For thumbsreconstructed with a pollic
17、ized index finger,good functionis dependent on the retention of the thenar muscles.9Otherwise,the reconstructed thumb functions as a postonly for grasping and pinching.Unfortunately,with many severe thumb injuries,aconcomitant index finger injury is common.In these cases,the index finger stump can b
18、e pollicized and used for thumbreconstruction.12e14In the presence of a concomitant indexfinger amputation,the index metacarpal is then perfusedby the first dorsal metacarpal artery and venae comitans.15Pollicization of a damaged or shortened index metacarpalcannot,however,restore the full length,fu
19、nction,andappearance of a normal thumb.In the present study,we describe our technique for thereconstruction of very proximal thumb amputations at themetacarpal base and trapeziometacarpal joint,combinedwith index finger amputations at the metacarpal level,withpollicization combined with bilateral co
20、mposite toe trans-fer.All toes are preserved with this technique.MethodsPatientsBetween 2010 and 2014,eight patients underwent recon-struction.A retrospective review was performed afterinstitutional review board approval.Four patients couldreturn for follow-up.Demographic data are presented inTable
21、1.Three patients were male and one was female.Themean age was 24.5(range 17e29).The mean duration offollow-up was 23.3 months.The right hand was affected inthree cases,and the left hand was affected in one case.Allcases had sustained traumatic amputation of the thumb atthe metacarpal base level toge
22、ther with concomitant indexfinger amputation at the metacarpal level.In addition,allcases had functional thenar muscles,and three had normalcarpometacarpal joints.Surgical techniqueReconstruction of the thumb is achieved by the polliciza-tion of the remnant index ray.The technique for pollici-zation
23、iswelldescribed.9e15Thenacontralateralcomposite medial great toe pulp and vascularized secondtoe proximal interphalangeal(IP)joint flap are harvested toreconstruct the MCP joint of the thumb.The toe pulpprovides soft tissue coverage over the vascularized toe jointtransfer.Subsequently,an ipsilateral
24、 composite great toewrap-around and second toe proximal IP joint flap areharvested to reconstruct the thumb IP joint and the distalthumb.This prevents an overly thick thumb that resultswhen only a great toe transfer is performed.We havepreviously described our technique of great toe wrap-around flap
25、 reconstruction,preserving the weight-bearingplantar skin as a triangular flap.3In the hand,the pollicized index metacarpal is fused tothe trapezium by using a miniplate for stability.Then thecontralateral vascularized second toe joint is fixed to the1010Z.Chi et al.pollicized index metacarpal by us
26、ing a miniplate.This re-constructs the MCP joint of the thumb.The ipsilateralvascularized second toe joint is fixed distal to the contra-lateral vascularized joint by using a miniplate to recon-struct the IP joint of the thumb.Then the ipsilateral greattoe wrap-around flap is sutured around the dist
27、al thumb toreconstruct a normal-appearing thumb.Bilateral composite toe transfers are revascularized withthe proximal and distal stumps of the dorsal radial artery.The flexor digitorum profundus tendon of the pollicizedindex finger stump is sutured to the flexor digitorum longusof the contralateral
28、vascularized joint.This is then suturedto the flexor digitorum longus of the ipsilateral vascularizedjoint.A similar reconstruction is performed with theextensor digitorum communis tendon of the pollicizedindex stump and the extensor digitorum longus tendons ofthe toe transfers.The stump of the ulna
29、r or radial digitalnerve to the thumb is sutured to the ipsilateral commondigital plantar nerve supplying the fibular great toe andtibial second toe to restore sensation to the reconstructedthumb.The superficial branch of the radial nerve at theanatomical snuffbox is sutured to the contralateral com
30、-mon digital plantar nerve to restore sensation to the toepulp flap that is inset at the dorsal thumb base.A neurotized superthin anterolateral thigh flap is used toreconstruct the ipsilateral toe defect that is purely dorsal,while bone defects of the bilateral second toes are recon-structed with co
31、rticocancellous iliac crest bone grafts.Theend result is preservation of all toes of both feet.Because of the complexity of the procedure,at least twosurgical teams are involved in the procedure.One teamraises the flaps,while the other team concurrently pre-pares the hand and proceeds with the micro
32、vascularportion of the procedure to reduce surgical time.All pa-tients are referred to a hand therapist postoperatively.Theprotective splint is removed 1 week postoperatively,and aremovablesplintismaintaineduntil3weekspost-operatively.Activerangeofmotionexercisesarecommenced at the MCP and IP joints
33、 at 3 and 4 weekspostoperatively,respectively.ResultsTable 1 shows outcome data for all patients.All patientshad functional opposition and key pinch.The contour andlength of the reconstructed thumbs were similar to thoseon the contralateral side.The mean disabilities of the arm,shoulder,and hand(DAS
34、H);mean Michigan hand outcomesquestionnaire(MHQ);and mean foot and ankle disabilityTable 1Demographics and outcome data.PatientAgeGenderFollow-upMechanism of injuryDASHMHQFADISide of defect(Years)(Months)ScoreScoreScore129Male23Machine1.78599Right217Male24Crush15.77178.8Right327Female22Machine7.5809
35、9Right425Male24Blast586100Left*DASH:Disabilities of the arm,shoulder and hand;MHQ:Michigan hand outcomes;FADI:Foot and ankle disability index.Figure 1Preoperative images of patient 4 who sustained aleft thumb amputation at the trapeziometacarpal joint leveland amputation of an associated index finge
36、r at the distalmetacarpal.(A)Lateral view.(B)AP radiograph.Reconstruction of thumb amputation at the metacarpal base level1011index(FADI)scores were 7.5,80.5,and 94.2,respectively.The mean range of motion of the reconstructed MCP jointand the reconstructed IP joint was 20 and 15?,respectively.All fl
37、aps survived,and there were no complications of note.Case example(patient 4)A25-year-oldmanlosthisleftthumbatthetra-peziometacarpaljointlevelfollowingablastinjury.Associated injuries to the left hand included index fingeramputation at the metacarpal shaft level(Figure 1).Reconstruction was performed
38、 17 months after the initialinjury.The reconstruction consisted of pollicization of thesecond metacarpal stump with a contralateral great toehemipulp and vascularized second toe joint,with an ipsi-lateral great toe wrap-around and second toe vascularizedjoint transfer(Figure 2).A neurotized superthi
39、n antero-lateral thigh flap was used to reconstruct the ipsilateralFigure 2Intraoperative images of patient 4 showing toe flap harvest.On the right contralateral side,a great toe medialhemipulp flap was harvested together with the second toe proximal interphalangeal joint and its flexor and extensor
40、 tendons.(A)Preoperative markings.(B)After flap harvest.On the left ipsilateral side,a wrap-around great toe flap was harvested together withthe second toe proximal interphalangeal joint and its flexor and extensor tendons.(C)Preoperative markings.(D)After flapharvest.1012Z.Chi et al.great toe donor
41、 site defect(Figure 3).The flap was suturedto the remnant plantar triangular flap to achieve completecoverage of the great toe donor site.Figure 4 shows the hand after pollicization and prior totransfer of the first contralateral composite toe flap.Figure 5 shows the immediate postoperative result.F
42、igure 6shows the immediate postoperative radiograph of thereconstructed thumb.Figure 7 shows the 2-year post-operative result with opposition of the thumb to the smallfinger.The contour and length of the reconstructed thumbare similar to those of the contralateral uninjured digit.Static two-point di
43、scrimination(2PD)of the reconstructedthumb was 5 mm.The DASH,MHQ,and FADI scores were 5,86,and 100,respectively.The videos presented in this study show good function 1year postoperatively.Video 1 shows the opposition of thethumb to all three remaining fingers.Video 2 shows thepatient writing and man
44、ipulating a bottle.Video 3 showshow he can play basketball,gripping and shooting the ballwith his left reconstructed hand.He can ride his motorcycleand perform repairs with his left hand holding a screw-driver.Donor sites in both feet are well healed,and hewalks and runs normally.Supplementary data
45、related to this article can be foundonline at http:/dx.doi.org/10.1016/j.bjps.2017.05.032.DiscussionReconstruction of an amputated thumb proximal to themetacarpal joint is very challenging.In this scenario,aFigure 3Intraoperative images of patient 4 showing right anterolateral thigh harvest for the
46、resurfacing of left contralateralgreat toe donor site defect.(A)Thigh markings.(B)Prior to inset of flap.Figure 4Intraoperative image of patient 4.The pollicizationhas been performed,and the base of the second metacarpal isfused to the trapezium with a plate.The harvested rightcomposite great toe me
47、dial hemipulp and the second toevascularized joint flap are ready for inset.Reconstruction of thumb amputation at the metacarpal base level1013simple toe transfer will not suffice as the problem is lengthand soft tissue coverage.Previously described techniquesinvolve preliminary distraction lengthen
48、ing,placement ofan iliac crest bone graft,or osteoplastic reconstructionprior to definitive toe transfer.2e8When thumb recon-struction was performed using a groin flap followed bysecond toe transfer with metatarsal,pinch and oppositionwas possible for all patients,with six out of eight patientsin a
49、series registering grip strength of at least 50%of theopposite hand.4Functional outcome scores were notassessed.When distraction of the metacarpal followed bysubsequent toe transfer was performed,average pinchpower was 66%of the opposite hand and the mean static2PD was 8 mm.5When osteoplastic recons
50、truction was usedas the primary technique with or without secondary toetransfer,54%of patients achieved opposition,while 62.5%achieved basic hand function.6Unfortunately,many ofthese techniques often result in a post that does not havefunction nor resembles a normal thumb.Pollicization,however,can r