Search

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.

Background Most of the frequently used methods for finger reconstruction have their own limitations. Reconstruction of a full-length finger with normal appearance, in patients with proximal digital amputation, remains a challenge. Methods Between January 2002 and November 2013, a total of 86 fingers (60 patients) with proximal phalanx amputation were surgically repaired. A compound flap comprising an expanded wraparound flap from the great toe and a vascularized proximal interphalangeal (PIP) joint from the second toe was harvested to reconstruct a full-length finger. The flap was used to reconstruct the nail, skin, and the distal phalanx; the PIP joint was used to reconstruct the PIP joint. To attain normal length of the finger and right PIP joint positioning, an iliac bone graft was inserted into the distal-middle or proximal phalanx. Results All reconstructed fingers retained their viability and natural appearance and were of near-normal length with a normal PIP joint positioning; 12.8% (9/86) of the procedures required re-exploration owing to compromised circulation. Secondary procedures were required in 71% (61/86) of the cases. With the exception of 1 case, the donor-site complications were mild; the average range of motion at the other PIP joints was 52 degrees (-15 to -5 degrees of extension, 25-90 degrees of flexion). Approximately 80% of the normal functionality and 93% of the normal appearance with respect to aesthetics were restored. Conclusions The full-length finger reconstruction procedure allows for construction of natural-appearing full-length fingers with normal PIP joint positioning and a near-normal functional recovery for proximal digital amputation. The operation is technically complex and time consuming and demands a skilled operator for successful outcomes.

Palatal fistula is a known complication of cleft lip-cleft palate repair. Fistulas anterior to the incisive foramen can be particularly difficult to repair because of the lack of available tissue. Adjacent tissue has inherent limitations, and multiple free-flap techniques have been described; however, there remains no single solution for this difficult problem. The authors present an alternative strategy of replacing "like with like" by using an osteocutaneous free tissue transfer of the second toe for anterior oronasal fistulas. Use of the osteocutaneous second-toe free flap provides skin lining to both the oral side and the nasal side to close oronasal fistulas. It also bridges the alveolar gap with vascularized bone. This flap can be considered as an elegant alternative for anterior oronasal fistulas.

AB Purpose: This study aimed to establish whether the peak plantar pressures generated by overweight and obese school-age children during walking were associated with their objectively measured physical activity. Methods: Physical activity levels of a subset of 73 overweight/obese children from a randomized controlled trial (mean +/- SD: age, 8.3 +/- 1.1 yr; 47 girls; body mass index z-score, 2.7 +/- 0.7) were objectively measured using accelerometers. Plantar pressure distributions were also quantified as the participants walked over a pressure platform. Pearson product moment correlation coefficients were calculated to determine the strength of the relations between the peak plantar pressures generated during walking and the physical activity levels for overweight/obese children. Results: Peak pressures generated beneath the forefoot during walking were inversely correlated with time spent in different intensity levels of physical activity. Moderate-intensity (r = -0.321, P = 0.007), vigorous-intensity (r = -0.326, P = 0.006), and moderate- to vigorous-intensity (r = -0.342, P = 0.004) physical activity were significantly correlated with middle forefoot pressure and with lateral forefoot pressure (r = -0.248, P = 0.040; r = -0.264, P = 0.028; r = -0.267, P = 0.027, respectively). Lateral midfoot (r = -0.244, P = 0.044) and second toe (r = 0.227, P = 0.021) pressure were also significantly correlated with vigorous-intensity activity. Conclusions: Those children who generated higher pressures beneath their forefoot and midfoot during walking had lower levels of physical activity. Further research is required to determine the long-term effects of excessive body mass on participation in physical activity and whether the walking plantar pressure patterns associated with reduced physical activity are related to foot pain or discomfort.

Lesser toe deformities are caused by alterations in normal anatomy that create an imbalance between the intrinsic and extrinsic muscles. Causes include improper shoe wear, trauma, genetics, inflammatory arthritis, and neuromuscular and metabolic diseases. Typical deformities include mallet toe, hammer toe, claw toe, curly toe, and crossover toe. Abnormalities associated with the metatarsophalangeal (MTP) joints include hallux valgus of the first MTP joint and instability of the lesser MTP joints, especially the second toe. Midfoot and hindfoot deformities (eg, cavus foot, varus hindfoot, valgus hindfoot with forefoot pronation) may be present, as well. Nonsurgical management focuses on relieving pressure and correcting deformity with various appliances. Surgical management is reserved for patients who fail nonsurgical treatment. Options include soft-tissue correction (eg, tendon transfer) as well as bony procedures (eg, joint resection, fusion, metatarsal shortening), or a combination of techniques.

Second toe-to-thumb transfer is a good alternative to using the great toe for reconstruction of the thumb. It achieves excellent function and reduces morbidity to the donor foot. However, cosmesis is often poor. The second toe has three unattractive features, a narrow "neck," a bulbous tip, and a short nail.The authors describe a modified second toe transfer that addresses cosmesis in six patients. These include (1) harvesting a flap from the adjacent side of the great toe and insetting it into the volar aspect of the second toe to give more bulk, (2) making skin excisions on each side of the tip to reduce the bulbous appearance, and (3) excising the eponychium to produce apparent lengthening of the nail.The mean follow-up period was 18 months (range, 6 to 36 months). The procedure resulted in good function and improved cosmesis in all six cases. Part of the great toe flap was lost in one case. The mean two-point discrimination in the transferred toes was 10.1 mm, with protective sensation present in the flaps. The range of motion of the transferred toe was 14 to 38 degrees at the metatarsophalangeal joint, 16 to 55 degrees at the proximal interphalangeal joints, and 20 to 36 degrees in the distal interphalangeal joints. All patients except one were happy with the appearance of the transferred toe.This novel approach will allow patients to take advantage of the lower morbidity to the donor site afforded by second toe-to-thumb transfer and provide the patients with a more aesthetic appearance of the new thumb.

Objectives/Interrogation: As an alternative to pollicization, Chow et described a non-vascularized longitudinal hemi-metatarsal second toe transfer to reconstruct the CMC joint of the Blauth grade IIIb or IV hypoplastic thumb. Previously others described the whole second toe MTPJ transfer. We describe[for full text, please go to the a.m. URL], 14th Triennial Congress of the International Federation of Societies for Surgery of the Hand (IFSSH), 11th Triennial Congress of the International Federation of Societies for Hand Therapy (IFSHT), 11th Triennial Congress of the International Federation of Societies for Hand Therapy (IFSHT)

Case Closed reduction was unsuccessful in a 6-year-old girl with a dislocated proximal interphalangeal joint of the second toe. Surgical exploration revealed soft-tissue entrapment by a ruptured medial collateral ligament. After the entrapment was cleared, the joint was reduced but remained unstable. The ligament was repaired with an all-suture mini-anchor to restore stability. The patient had a good recovery, and normal toe function had been restored by 3 months. Conclusion This rare case demonstrates the safety of the use of all-suture mini-anchors in treating similar injuries in children because they leave a minimal footprint and a minimal amount of foreign material.

Background: The authors reviewed their results with simultaneous double second toe transfer for reconstruction of adjacent fingers. Methods: From January of 1984 to January of 2003, simultaneous double second toe transfer was performed for reconstruction of adjacent fingers in 140 patients (48 before wound closure, 92 after). Functional thumbs were present in all of them. There were 104 male and 36 female patients, with an average age of 29.1 years (range, 2 to 57 years). Index and middle fingers were reconstructed in 90 patients, middle and ring fingers in 49 patients, and ring and little fingers in one patient. The average operation time was 11 hours 25 minutes, which was much shorter than double the average time of a single second toe transfer (8 hours 31 minutes; double time, 17 hours 2 minutes). Twenty-six toes were reexplored for vascular insufficiency and three of them were lost. Secondary surgery was performed in 98 patients to improve function and cosmesis. Results: Patients were followed up at an average period of 47.5 months (range, 2 to 210 months). Forty-two patients had complete functional evaluation at a minimum 2-year follow-up. The mean active range of motion of the reconstructed finger joints in these patients was 69.4 degrees for metacarpophalangeal joints, 31.1 degrees for proximal interphalangeal joints, and 8.2 degrees for distal interphalangeal joints. Two-point discrimination was between 3 and 13 mm (average, 7.5 mm). All donor sites were closed primarily and no obvious donor-site morbidity was noted, except for one hallux valgus deformity that was corrected by surgery. Conclusions: The functional and aesthetic results of double second toe transfers for adjacent two-finger reconstruction are superior to those of a single second toe-to-single finger reconstruction in multiple-finger amputations. Double second toe transfer performed simultaneously reduces the cost and total time of the operation, enables faster rehabilitation, and hastens patient adaptation.

Utilizing the tissue obtained from the plantar surface (metatarsophalangeal-distal interphalangeal region) of the second toe is an ideal procedure for reconstruction of partial finger tissue defects. The major advantage of this method is that it provides satisfactory aesthetic and functional improvement at the recipient site: furthermore, good results from the aesthetic point of view and minimum morbidity at the donor site are obtained. Our procedure utilizes the free neurovascular skin flap (second toe plantar flap) and full-thickness skin graft. As for the free flap, artery and nerve are obtained from the plantar neurovascular bundle and vein from the dorsal or plantar vein. All cases reconstructed with this procedure revealed satisfactory sensory restoration and aesthetic appearance. The donor sites also revealed no contracture and visible scar. In this paper, we discuss the application of this procedure for finger tissue reconstruction.

A combination procedure was performed on the medial two toes in a 6-month-old child with preaxial polydactyly of the left foot. The first toe had the appearance of a cosmetically intact great toe, but the second toe had better function. A method to combine the advantages of these two toes was therefore applied, with favorable results seen at 1.5 years after surgery.

From 1966 to 1989, we performed free toe transfer for thumb and finger reconstruction in 300 patients, with 286 survivals and 14 failures, a total survival rate of 95.55 percent. Follow-up for 2 to 23 years showed that movement and sensation of the reconstructed thumbs and fingers were satisfactory in all of the 286 cases. The optimal indications for the operation were defect of the thumb at the plane of the metacarpophalangeal joint and defects of the second to fifth fingers. Besides atraumatic isolation of the second toe and sophisticated microsurgical suturing technique, special attention was paid to intraoperative vascular variations, to providing the double arterial blood supply system if necessary, and to the identification and management of postoperative circulatory crisis.

Three hundred and thirty feet in 265 patients with polydactyly of the foot were classified on the basis of ray involvement and the level of duplication. Anatomic differences in bony structures according to x-ray and operative findings, external appearance of involved digits, associated anomalies, and familial incidence were studied. In medial-ray polydactyly, bilateral occurrence was common, and a higher frequency of associated anomalies was detected. Each involved foot with even the same level of duplication usually had a different morphologic pattern. In central-ray polydactyly, all patients except one had duplications of the second toe, commonly with unilateral involvement. Both components were underdeveloped, with delay in appearance of ossification areas. In two patients, each member of duplication had syndactyly with the neighboring toe, resembling the pattern of polysyndactyly-cleft hand complex. Lateral-ray polydactyl was classified into two new major groups based on ossification pattern and bony alignment: (1) fifty-ray duplication, referring to the medially duplicated supernumerary fifth toe, and (2) sixth-ray duplication, referring to the laterally duplicated supernumerary sixth toe. Fifth-ray duplication was much more frequent than sixth-ray duplication in the Japanese population. Many differences were noted between the two groups of lateral polydactyly. Syndactyly between the fourth and fifth toes was associated only with fifty-ray duplication. Ulnar polydactyly was associated only with sixth-ray duplication. In lateral polydactyly, every patient with bilaterally involved feet had similar groups of polydactyly bilaterally. All the patients in the same family also had similar groups of anomalies. These facts suggest independent etiologic mechanisms for each.

The microsurgical second toe wrap-around technique is an ideal treatment option for reconstruction of the distal half of the finger with circumferential loss of skin and nail associated with an uninjured proximal interphalangeal joint and an intact insertion of the flexor digitorum superficialis tendon. Follow-up of 13 flaps in 10 patients from 1986 to 1989 demonstrates rapid and adequate functional recovery as well as satisfactory aesthetic appearance in all patients.

The free vascularized osteocutaneous flap from the big toe has been offered as a solution for the reconstruction of the distal phalanx of the fingers. As another important application of this flap, it is recommended that the flap pedicled with the plantar vessels can easily cover the defect involving the bone of the second toe.

Dermatofibrosarcoma protuberans is an unusual soft-tissue tumor with a propensity for local recurrence and occasional metastatic spread. Given its indolent course, it may be mistaken for atypical scarring or a keloid growth. Most lesions are trunkal or on the proximal extremities with digital lesions being extremely rare. There is only one previous reference of the tumor arising on a toe. Early diagnosis and prompt wide local resection of this entity are required to prevent a local recurrence, which would necessitate a wider, more debilitating resection. The management of a patient with a dermatofibrosarcoma protuberans of the second toe is presented along with a review of the literature.

Nine patients had replacement of the thumb and seven, reconstruction of a finger in a mutilated hand in which the thumb or all fingers had been amputated. There were twelve successes, three partial successes, and one failure. A clear knowledge of the anatomy of the dorsalis pedis artery, avoidance of kinking of the vessels, and adequate precautions against postoperative edema and venous congestion were essential for success. The donor foot did not suffer functionally despite the absent second toe.

Complex syndactyly of the hands and feet is a major deformity seen in children with Apert's syndrome. Also observed in the three patients presented in this paper was severe hallux valgus, which caused significant shoeing difficulties in two patients, for whom surgical correction was necessary. The two operative plans were based on the different underlying osseous abnormalities: (1) removal of the great toe with transposition of the second toe; (2) resection of the second ray with realignment of the great toe. Both procedures were successful from a functional and aesthetic viewpoint. When confronted with a child with Apert's syndrome who is having shoeing difficulty, assessment of the underlying osseous pathology is a mandatory step in the preoperative planning of surgical intervention.

A second toe to hand transfer is described for thumb reconstruction which includes the extensor digitorum brevis as a simultaneous opponensplasty. This procedure was effective in a young man injured in a bomb explosion that completely destroyed the first ray. The second toe was dissected in continuity with the extensor digitorum brevis muscle, its nerve was anastomosed to the motor branch of the median nerve. Thus a one-stage operation allowed a complete reconstruction of the first ray proximally to the trapezium. Recovery at 2 years is good, and the muscle transfer can be demonstrated to work.

Over a period of 6 years, 54 toe-to-hand transfers were performed, 24 for thumb and 30 for finger reconstruction. Refinements in evaluation, preparation, and surgical technique are detailed. Forty-nine toes (90.7 percent) survived. Exploration was required for circulatory compromise following 13 transfers (34.2 percent), to good effect in 9 (69.2 percent). Secondary surgery was performed in 26 cases, consisting of tendolysis, osteotomy, and deepening of the first web space. Review was undertaken at an average of 1 year and 9 months after transfer. Power grip averaged 28.5 percent of the normal hand and pinch strength 26.6 percent, great toe transfer giving 35.7 percent and second toe transfer to thumb giving 15.6 percent strength compared with normal. Static two-point discrimination of less than 10 mm was present in 37.5 percent of those studied under 2 years after surgery and in 75 percent of those studied more than 2 years later. The choice of procedure for thumb reconstruction is discussed in detail, as are supplementary skin cover, vascular considerations, and the high exploration rate.