Distal thumb reconstruction with a great toe partial-nail preserving transfer technique

The great toe partial-nail preserving transfer technique is another modification for distal thumb reconstruction in composite defects at or below the interphalangeal joint of the thumb. Noting the size difference of the nail width between the great toe and thumb, the authors dissected only a thumb nail width and skin flap from the great toe, leaving the remainder of the medial skin flap and nail of the great toe at the donor site. A total of 25 cases between 1993 and 1996 were performed using this technique, and the mean follow-up period was more than 12 months. The reconstructed thumb had a better cosmesis with a more natural appearance. At long-term follow-up, the thumb nail width decreased an average of 1.8 mm, but the pulp volume was almost the same as that of the normal contralateral side. The average static 2-point discrimination was less than 9.0 mm. In cases with preserved interphalangeal joint, an average of 48 degrees of range of motion with key-pinch of 80 percent of that of the normal contralateral thumb was achieved. The final appearance of the donor site with partial nail looks like a brachymetatarsia.     

Microsurgical thumb reconstruction with toe transfer: selection of various techniques

Microsurgical toe transfer is an established method for reconstruction of missing thumbs. However, there is little agreement on which of the various techniques represents the ideal transfer. Basically, selection of technique requires balancing the patient's functional needs, appearance of the reconstructed thumb, and donor-site cosmesis. Based on our experience with 103 toe-to-thumb transfers performed over the past 9 years, this paper attempts to provide guidelines for appropriate selection among the four most commonly employed toe transfer techniques (e.g., second toe, total great toe, great toe wrap-around, trimmed great toe) so that optimal results and patient's acceptance can both be achieved.     

Toe transplantation in congenital malformations of the hand

Toe transfer is a well established procedure for thumb and finger reconstruction after mutilation. The indications in congenital malformations are a mater of controversy. Out of a personal series of 209 patients, 42 were children presenting a congenital malformation. Thirty six, with 46 transfers were available for review. There is only one failure at the beginning of our experience. The main indication was absence of pinch either due to absence of thumb (like in congenital band syndrome or some extreme cases of ulnar club hand or cleft hand) or absence of long finger (like in symbrachydactyly monodactylous type) or lack of both thumb and finger (like in peromelic type of symbrachydactyly). In this last type, we have been disappointed by the functional result of the distal implantation of two second toes taken from both feet; we have proposed a "stub" operation consisting in a second toe transfer on the anterior aspect of the radial epiphysis to take advantage of the mobility of the wrist and the availability of plenty tendon transfer (in this proximal situation). When planing to "built" an absent pincer, an early age is mandatory for operation (mean 12 months), to ensure a good cortical integration. A less frequent indication is a partial toe transfer with a vascularized epiphysis to provide growth and mobility in some cases of thumb hypoplasia (like in symbrachydactyly or Blauth and Manske type III b). Results are difficult to assess due to the early operation but if the mobility has been disappointing (mean 32 degrees), sensibility (mean 2PD 5 mm) and growth were excellent.     

Management of the amputated thumb

Two cases are described, one of replantation of an amputated thumb, the other of late reconstruction by toe transfer. A possible reason for the good results in thumb replantation is mentioned, and the advantages of toe transfer in thumb reconstruction are discussed. Suggestions are made as to the course of action to take when confronted with a patient with an amputated thumb.     

Effects of the neuropeptide thyrotropin-releasing hormone on GABAergic synaptic transmission of CA1 neurons of the rat hippocampal slice during hypoxia

Thirty-six consecutive patients with 37 complete tears of the ulnar collateral ligament of the thumb metacarpophalangeal (MP) joint were treated with primary repair using a miniature intraosseous suture anchor. Thirty patients were evaluated by clinical examination or by questionnaire at an average of 11 months after repair. Loss of interphalangeal joint motion averaged 15 degrees on the involved side versus the other side, while loss of MP joint motion averaged 10 degrees. There was no significant difference on stress testing measurements between repaired and nonrepaired thumbs. There were no instances of nerve injury, infection, device failure, or reoperation. The authors concluded that this is a safe and effective method for repair of complete tears of the ulnar collateral ligament of the thumb MP joint.     

Mechanisms of the reproductive system aging and hormonal carcinogenesis: modification caused tobacco smoke exposure

We have studied the recovery of post-tetanic count and train-of-four responses at the great toe and thumb accelerographically after the administration of vecuronium 0.2 mg.kg-1. Sixty adult patients scheduled for anaesthesia with nitrous oxide and isoflurane were studied. The times to the return of the first post-tetanic twitch were comparable at the great toe and thumb (mean (SD) times: 30.0 (6.5) min and 35.0 (8.5) min, respectively). Recovery of post-tetanic count followed similar time courses at the great toe and thumb. Also, time to the return of the first twitch of the train-of-four did not differ significantly at the great toe and the thumb (47.5 (9.6) min vs. 49.7 (10.5) min). Similarly, time to the return of the second, third and fourth twitches of the train-of-four did not significantly differ at the great toe and the thumb. However, the value of the first twitch of the train-of-four, expressed as a proportion of control twitch, was significantly higher than that at the thumb between 50 min and 110 min after the vecuronium injection, and the train-of-four ratio at the great toe was significantly higher than that at the thumb between 60 min and 100 min after the vecuronium injection.     

Toe transplantation for isolated index finger amputations distal to the proximal interphalangeal joint

Functional deficit following single distal index finger amputations has been considered insignificant, and reconstruction is usually not recommended. Herein, 19 cases of second toe transplantation for reconstruction of isolated index finger amputation distal to the proximal interphalangeal joint are presented with long-term functional results. There are 14 men and 5 women. The average age was 26 years. The toe transplantations were performed either as a primary procedure (5 patients) while the wounds were still open or as a secondary procedure (14 patients) after the wounds healed. In 11 patients, the dominant hand was involved. All toes survived completely, although re-exploration was required in three cases (16 percent). The functional evaluation included (1) sensory recovery, where the average static and moving two-point discrimination were 8 mm (range 4 to 15 mm) and 6 mm (range 2 to 15 mm); (2) motor function, where the average of index-thumb pulp-to-pulp pinch compared with the normal hand was 67.5 percent (range 36 to 96 percent); (3) average range of motion in index finger joints (extension/flexion), where metacarpophalangeal joint was 14/90, proximal interphalangeal joint was 0/94, and distal interphalangeal joint was 19/38; and (4) functional and cosmetic results, where percentage of involvement in daily activities and functional capacity of the reconstructed index were 69 percent and 70.5 in average, respectively, over a total score of 100. Average scores of aesthetic appearance and acceptability of donor-site deformity were 74 and 87.5 over a total score of 100, respectively. Toe transplantation for distal index finger amputations improved hand function when performed in selected patients with specific job requirements or high motivation.     

Reconstruction of a congenital hypoplastic thumb with use of a free vascularized metatarsophalangeal joint

Reconstruction of a Blauth type-IIIB hypoplastic thumb with use of a free vascularized metatarsophalangeal joint was performed in four patients (four hands). Several tendon transfers also were performed, either primarily or secondarily, to mobilize the reconstructed thumb. Three patients (three hands) were followed for at least two years after the reconstruction; the results for these three patients were compared with those for four patients (six hands) who had been managed with pollicization of the index finger because of a similar deformity of the thumb. The patients were evaluated with regard to grip strength, key-pinch strength, and the range of motion of the joints of the thumb in the operatively treated and contralateral hands as well as with regard to skill in performing activities of daily living as assessed with use of the Kobe hand-function test. Although the appearance of the thumb was closer to normal in the group that had had the pollicization procedure, total function of the hand and grip strength were greater in the group that had had the transfer procedure. We believe that reconstruction of an unstable hypoplastic (Blauth type-IIIB) thumb with use of a vascularized metatarsophalangeal joint is an acceptable alternative to pollicization of the index finger.     

Heterotopic replantation

In multidigital amputations, it is sometimes better to replant an amputated finger to a different proximal part if a better function can be expected in this position. In our clinical material between October 1991 and March 1994, heterotopic replantation was performed in twelve digits in eleven patients. Three fingers were replanted to the thumb, three to the index, four to the middle, and two to the ring fingers. The functional results were satisfying. The total active range of motion was on an average 24% of a normal finger. Static two-point discrimination was 8.5 mm on an average, and the values for the Semmes-Weinstein test ranged between 3.61 and 6.5. A heterotopic replantation is of special value for primary thumb reconstruction.     

Simple excision of the trapezium for osteoarthritis of the carpometacarpal joint of the thumb

We have reviewed the results in 34 patients (39 operations) following simple excision of the trapezium for osteoarthritis of the basal joint of the thumb. The average age at operation was 57 years and the average follow-up was 6 years. All the patients were graded clinically and radiologically and were asked their opinion of the procedure. There was dramatic relief of pain following this procedure. Stability of the thumb was not compromised. When compared to the unoperated side, thumb length, thumb abduction and first web span were similar. There was a reduction in pinch strength (operated 8.1 k.p.a., non-operated 9.6 k.p.a.) and grip strength (operated 15.5 k.p.a., non-operated 19.5 k.p.a.) and an increase in MIP extension (operated 5.4 degrees, non-operated 2.9 degrees) following this procedure but the differences were not statistically significant. 11 patients (32%) had scar hyperaesthesia on testing but this was a clinical problem in two patients only (5%). Simple excision of the trapezium is a satisfactory procedure for the majority of patients with this disorder, but has a long post-operative rehabilitation period.     

Closed reduction of a rare type III dislocation of the first metatarsophalangeal joint

OBJECTIVE: To discuss a rare Type III dislocation of the first metatarsophalangeal (MP) joint, without fracture, that used a closed reduction technique for correction. CLINICAL FEATURES: A 43-yr-old man suffered from an acute severe dislocation of his great toe as the result of acute forceful motion applied to the toe as his foot was depressed onto a brake pedal to avoid a motor vehicle accident. Physical examination and X-rays revealed the dislocation, muscle spasm, edema and severely restricted range of motion. INTERVENTION AND OUTCOME: The dislocation was corrected using a closed reduction technique, in this case a chiropractic manipulation. Fourteen months after reduction, the joint was intact, muscle strength was graded +5 normal, ranges of motion were within normal limits and no crepitation was noted. X-rays revealed normal intact joint congruency. The patient experienced full weight bearing, range of motion and function of the joint. CONCLUSION: Although a Type III dislocation of the great toe has only once been cited briefly in the literature, this classification carries a recommended surgical treatment protocol for correction. No literature describes a closed reduction of a Type III dislocation as described in this case report. It is apparent that a closed reduction technique using a chiropractic manipulation may be considered a valid alternative correction technique for Type III dislocations of the great toe.     

Hallux-to-thumb transfer by microvascular anastomosis

The replacement of a missing thumb with a big toe transferred as a free vascularized composite graft is described. The anatomical basis relating to this transfer is described and the methods and the advantages and disadvantages of this as alternative thumb reconstruction are discussed. To the best of our knowledge, this procedure is the first of its kind to be undertaken in South Africa.     

Effect of the extramitochondrial adenine nucleotide pool size on oxidative phosphorylation in isolated rat liver mitochondria

We report a long-term follow-up of abduction-extension osteotomy of the first metacarpal, performed for painful trapeziometacarpal osteoarthritis. Of a consecutive series of 50 operations, 41 thumbs (82%) were reviewed at a mean follow-up of 6.8 years. Good or excellent pain relief was achieved in 80%, and 93% considered that surgery had improved hand function, while 82% had normal grip and pinch strength, with restoration of thumb abduction. Metacarpal osteotomy was equally successful in relieving symptoms of those with early (grade 2) and moderate (grade 3) degenerative changes. This simple procedure provides lasting pain relief, corrects adduction contracture and restores grip and pinch strength, giving good results with few complications.     

Surgical principles and planning for the rheumatoid hand and wrist

Each surgical procedure available for the rheumatoid hand has a score card. The most indicated and necessary procedures include: extensor tenosynovectomy and Darrach for the impending or already ruptured extensor tendons; flexor tenosynovectomy and carpal tunnel release for the patient with impaired median nerve function; stabilization of the deformed unstable thumb with MP or IP arthrodesis; and flexor tenosynovectomy in the palm and finger of a motivated patient with significant disparity between active and passive motion. Relative indications for surgery include arthrodesis for the unstable wrist; MP arthroplasty for the fixed MP volar and ulnar subluxation with inability to open the hand; synovectomy for the occasional patient with painful boggy synovitis of the MP or PIP joint; and reconstruction of the fixed swan neck deformity with relatively good PIP joints. Both MP and PIP joints can and should be operated on at the same time. Extensive wrist surgery, that is, tenosynovectomy and Darrach or arthrodesis, should not be performed at the same time as MP arthroplasty. Try to do the "winner operations" first.     

Pollicisation of the index finger. A 27-year follow-up study

We have reviewed 11 patients with congenital absence of the thumb, treated by pollicisation of the index finger, after follow-up for 20 to 38 years. Seven of the hands also had an associated radial club-hand deformity. Function as assessed by the Percival score was excellent in six, good in three, fair in two and poor in four; three of the poor results were in patients with radial club hand. Ten of the 15 transfers were used as normal thumbs, but in five hands function required trick movements. Of the seven unilateral cases, two transplants were used as the dominant hand, and in another two thumb strength was more than 50% of that on the opposite side. For patients with isolated congenital absence of the thumb, pollicisation of the index finger gives good functional and cosmetic results which are maintained. The results are less reliable for those with radial club hand.     

Experimental study on the effects of tension-reduced early mobilization on extensor tendon healing

Numerous clinical and experimental studies have been reported on early postoperative mobilization after flexor tendon repair. However, there have been only a few experimental studies reported on extensor tendon repair. In 1989, Ishiguro reported the usefulness of tension-reduced early mobilization in clinical cases of extensor tendon ruptures. The purpose of this experimental study was to examine the in vivo effect of tension-reduced early mobilization on extensor tendon healing in chicken. An experiment was performed on the extensor tendons of 218 chickens in an attempt to examine the effects of tension-reduced early mobilization on tendon healing and adhesion. The extensor tendon of the fourth toe was cut and the distal stump of the tendon was transferred to the extensor tendon of the third toe. Postoperatively two protocols were employed. In the immobilization group, a cast was applied for three weeks. In the early-mobilization group, immediate active motion of the digits was allowed. A tension-reduced position was maintained by taping the fourth toe to the dorsum of the third. The findings from the early mobilization group and from the immobilization group were as follows: 1. Macroscopically, sutures at the repair site of the early-mobilized tendon were not evident after three weeks because of fibrous connective tissue growth. Despite this abundant connective tissue, tendon gliding was observed to be smooth. Between the suture site and the gliding floor, loose connective tissue, similar to normal paratenon, was observed. Histology confirmed this observation. 2. The tensile strength required to extend the MP joint was significantly lower for the early-mobilization group than for the immobilization group, suggesting minimal adhesion between the sutured tendon and the gliding floor in the early-mobilization group. 3. No significant difference in tensile strength among the various tendon repair techniques employed was observed at the suture site.     

The treatment of older adult patients with acute myeloid leukemia by triple infusion chemotherapy

This retrospective study analyzed 202 toe-to-hand transplants performed over the last 20 years at the Davies Medical Center, San Francisco (USA). The overall success rate was 97%. Toe transplants for finger reconstruction yielded optimal functional and cosmetic results due to their anatomical similarity to fingers. The great toe was preferably used for thumb reconstruction, whereas the other toes were used for reconstruction of the long fingers. Early reconstructions, multiple simultaneous toe transplants, and interventions combining toe transplantation with free flaps seemed to be advantageous because of shorter rehabilitation and comparable results.     

The metacarpo-phalangeal arthrodesis of the thumb according to the tension-band principle: indications and technique

Arthrodesis of the thumb MP I remains a good procedure with numerous and various indications. It is especially valuable in heavy workers. The osteosynthesis, according to the tension-band principle, is stable and enables normal function of the hand after wound healing. The return to heavy work, however, requires at least 4 weeks and a pain free thumb.     

Thirty cases of duplication of the thumb. Operative results

Thirty cases of duplication of the thumb have been seen during a period of 8 years. Twenty-four children underwent surgery for a total of 25 operations, and these are reviewed after a follow-up of at least a year. Wassel's type IV was the most frequent type, occurring in 14 cases. There were 23 primary operations, and 2 reoperations for frontal deviation, which were secondary to operations done elsewhere. The average age at the time of operation was 16 months, the mean follow-up is 4 years (1 to 8 years). The results are analyzed according to Wassel's criteria. Regardless of the location of the duplication, function is unaffected, the structure of the thumb is good, and the parents are satisfied. However, examination revealed some loss of mobility in 10 cases, shortening of the thumb in 5 cases, instability of the collateral ligament in 3 cases and axis deviation in 10 cases. Six of these were clinodactyly at the IP, 1 a clinodactyly at the MP and 3 Z-shaped deformities at the IP and MP. The two reoperations were done to correct a significant loss of alignment, and in each the result was upgraded from "poor" to "fair". It seems that the end results are determined at the original operation which should be done before the 18th month. The thumb with the least function, usually on the radial side, is resected and the remaining component reconstructured. This includes centralization of the insertions of the extrinsic muscles, and reinsertion of the thenar muscles. Immobilization by pinning is usually done due to the need for an osteotomy during the surgery for realignment of the axis of the thumb. It must, however, always be remembered that this surgery is cosmetic rather than functional.     

Free combined thin wrap-around flap with a second toe proximal interphalangeal joint transfer for reconstruction of the thumb

The combined thin wrap-around flap from the big toe and the proximal interphalangeal joint of the second toe is characterized by (1) a single vascularized joint, which is used to preserve the second toe with a free iliac bone graft, (2) a thin wrap-around flap, which allows the pulpal fatty tissue on the remaining bone of the big toe to be retained and accept a skin graft, (3) a wrap-around flap with a partial distal phalangeal bone, and (4) a microplate for firm fixation at the proximal bone union and early joint motion. The advantages of this method are (1) the cosmetic appearance is excellent with use of the thin wrap-around flap; (2) there is joint motion in the reconstructed thumb with strong pinch and vice pinch; (3) the vascularized joint with a microplate allows for early postoperative motion; (4) bone grafting from another donor site is unnecessary; (5) bone growth is possible in children with open epiphyses; and (6) the big and second toes are preserved with minimal donor-site morbidity. This method is indicated for thumb losses at a level distal to the metacarpophalangeal joint or at the level of the proximal phalanx.