Simultaneous Reconstruction of Extensor Mechanism in the Free Transfer of Vascularized Proximal Interphalangeal Joint

From a recent systemic review, vascularized toe proximal interphalangeal joint (PIPJ) transfer achieved an average arc of motion (AOM) of merely 37 degrees for finger PIPJ reconstruction. Despite the technical refinement over the past 3 decades, the resulting active motion of the reconstructed joint remains unpredictable and often fraught with extension lag. The technique for vascularized toe PIPJ transfer at our institute has evolved over the years to its current state, with simultaneous extensor mechanism reconstruction being a major component. During the transfer, the quality of extensor tendons on the recipient finger and donor toe are carefully evaluated. If the central slip of finger extensor is destroyed but the quality of lateral bands is adequate, centralization of lateral bands overlying the transferred PIPJ is performed. If there is acceptable central slip remnant at the proximal phalanx level, modified Stack procedure is performed for central slip reconstruction while leaving the lateral bands in continuity. If both lateral bands are poor, modified Stack procedure is performed unless the central tendon of the toe is strong enough to extend the PIPJ. From November 2008 to October 2010, 7 joints were transferred with this modified technique. The average follow-up was 18.2 months. The average active AOM of the transferred PIPJ was 56.4 degrees. The average extension lag of the toe PIPJ was 10.7 and 16.4 degrees before and after the transfer, respectively. Simultaneous reconstruction of extensor mechanism decreases the extension lag without sacrificing AOM of the transferred PIPJ.