PRS, CGMH, Taiwan

1. Thumb reconstruction
Chapter 87
Charles J.Eaton
p. 835~p. 846
Pang-Yun Chou
02.15.2012

2. History
• Staged, pedicled toe-to-thumb transfer
– without microvascular anastomosis
– performed by Nicoladoni in 1898
• Phalangization
• Osteoplastic reconstruction
• Pollicization
• Pedicled digital transfers
– date back 100 years
• Digital neurovascular island flaps and free toe transfers
– developed 50 and 40 years ago

3. Indication
• A replanted thumb, seems to be the best possible
reconstruction
– Not always more functional than an amputation
properly revised at the same level
• Strong contraindications
– significant vascular disease
– short life expectancy
– chronic pain with disuse of the limb
– unreconstructable sensory loss
– unrealistic patient expectations

4. Evaluation
• What is the status of
the basal joint?
– CMC joint evaluated
clinically and
radiographically
– salvage by arthroplasty
A: Interphalangeal arthrodesis
B: Metacarpophalangeal arthrodesis
C: Soft-tissue arthroplasty of the carpometacarpal joint

5. Evaluation
• Is there a first web space
contracture or skin deficit?
– unappreciated skin loss
– scar contractures
– abductor muscle destruction
– Paralysis
– basal joint pathology
– adductor/flexor muscle
contracture
• Preliminary correction
should be considered
– often cannot be fully
corrected, even with
determined surgical efforts Release with reverse pedicled posterior
interosseous artery island flap.

6. Evaluation
• Are there problems with the remaining digits?
– Optimum length, mobility, and position of the thumb are all
judged with the remaining fingers
• Has the patient developed maladaptive patterns of use?
• Do the patient’s complaints match the apparent deficit?
– Thumb amputation less restricted use of the hand
– Crush/avulsion injuries may result in a wide zone of deep
scarring, with prolonged stiffness, swelling, intrinsic tightness
• What are the patient’s expectations?
– Function, then social presentation and aesthetics
– A technical triumph to the surgeon
• may be seen as a grotesque deformity by the patient

7. Type of deficiencies
• Thumb deficiencies
– Amputation
– Component loss
• Reconstruction
– emergency (possible replantation)
– urgent (fresh open wound)
– subacute (unhealed wounds)
• septic or flap-threatening
complications are greatest
– elective (healed wounds)
• Reconstructive priorities
– first healing
– then function

8. Component loss
• Skeletal injuries
– Anatomic reduction and fixation
– Nonreconstructible  IPJ & MPJ treated with arthrodesis,
but CMCJ best salvaged with soft-tissue arthroplasty
• Soft-tissue loss
– Skin grafts or flaps
• Composite loss
– urgent soft-tissue cover with skeletal stabilization and
possible bone grafting
• As with any mangling limb injury, the best time to
proceed with completion of amputation is at the first
operation

9. Component loss
• Because sensory perception is key to
effective use of the thumb, innervated
flaps are much preferred for contact
area resurfacing
• Innervated flaps
– Moberg palmar adv. flap
– Holevich FDMA flap from index
– Heterodigital N-V sensory “island” flaps
– Free finger or toe pulp flaps
• Standard local digital flaps
– V-Y adv.
– Dorsal or volar cross-finger flaps
• Noninnervated regional flaps
– Posterior interosseous
– Radial forearm and intrinsic muscle flaps

10. Holevich flap
The dorsal index finger skin may be mobilized on a narrow skin or subcutaneous
pedicle for transfer to the thumb. This flap has been used to resurface the distal
half of the palmar skin, including the entire pulp surface

11. Free pulp transfer
Emergency thumb pulp
resurfacing with free pulp flap
harvested from a ring finger
amputated in the same
accident.
A: Initial injury with
amputated ring finger and loss
of thumb soft tissue.
B: Tissue harvested from
amputated part.
C: Thumb after flap transfer.

12. Component loss

13. Component loss
• If circumferential soft-tissue
loss extends proximal to the
base of the proximal phalanx
– Distal phalanx eventually
avascular necrosis despite flap
cover  primary
interphalangeal disarticulation
should be considered
• Denuded skeleton should be
covered in a tubed or closed
flap not buried in a pocketCircumferential thumb resurfacing with
contralateral free radial forearm flap

14. Amputation
• Whenever
possible, replantation should
be considered for thumb
amputation.
• Amputation Distal to the
Metacarpophalangeal Joint
– Primary reconstructive goals are
length, stability, and adequate
web space
– Choices
• bone graft with a local flap
• osteoplastic reconstruction
• Phalangization
• distraction lengthening
• toe-to-thumb transfer

15. Amputation
• Amputation Proximal to the Metacarpophalangeal Joint
– thumb ray does not project beyond the web space skin
• Options when loss is through the distal metacarpal
– osteoplastic reconstruction
– pedicled finger remnant transfer
– Pollicization
– free toe transfer
• A proximal metacarpal amputation
– retains the basal joint but has no intrinsic muscles.
• With this or an amputation including the basal joint
– (a) if the fingers are functioning well
• provide a stable, static post to oppose the fingers
– (b) full-finger pollicization

16. Osteoplastic Thumb Reconstruction
• Best Indication/Unique Advantages
– Partial or distal subtotal amputation
– No digit is sacrificed
• Disadvantages and Special Requirements
– Multiple staged procedures
– Results may be unaesthetic
• bulky, floppy, No nail
– Additional neurovascular flap for sensibility

17. Osteoplastic Thumb Reconstruction
• Technique
– Combination of a bone graft
and flap to lengthen the thumb
remnant
– Three procedures
– Lengthening the skeleton with
an iliac crest bone graft
covered in a tubed distant flap
– Division
– Transfer of a neurovascular
sensory island flap from the
ulnar side of the middle finger
Partial amputation, lengthened with an iliac
crest bone graft wrapped in a tubed pedicled
inferior epigastric flap. Innervation with a
neurovascular sensory island flap transferred

18. Phalangization
• Best Indication/Unique Advantages
– Thumb lengthening by finger transfer is a possible
consideration (rare) if the thumb is nearly long
enough, such as base of proximal phalanx
– Usually this is a single-stage operation
• Disadvantages and Special Requirements
– Not provide much functional improvement
– Very unnatural appearance
• Particularly if the web is converted to a cleft by an aggressive
Z-plasty.

19. Phalangization
• This is a web-deepening procedure, results of which are so often
disappointing that it is rarely a good recommendation in view of
today’s alternatives
• To allow creation of the cleft
– Adductor muscle insertion is detached and repositioned proximally
– First web space is deepened with a Z-plasty
– Correction of an associated first web space contracture
• Require stripping of the entire ulnar border of the first metacarpal
• Capsulotomy of the basal joint.
– The mechanical advantage of the adductor is progressively lessened
with more proximal reattachment

20. Metacarpal Distraction lengthening
• Best Indication/Unique Advantages
– Distal subtotal amputation (region of [MCP] joint)
is an indication for this procedure and there is
little or no donor defect except scar.
• Disadvantages and Special Requirements
– Only limited lengthening is possible
– Absolute cooperation is required

21. Metacarpal Distraction lengthening
• Thumb’s metacarpal is lengthened using progressive adjustments of an
external fixator in the manner introduced by Ilizarov for the lower limbs
– Metacarpal exposed
– Fixator placed
• Corticotomy made circumferentially and subperiosteally through the metacarpal shaft
• Minimize medullary bone disruption
– After 1 week, distraction is begun at a rate of 1 mm per day
– MCP joint will be progressively flexed unless stabilized with a strong K-pin
• In small children
– new bone growth from the periosteum
– medullary bone may adequately fill in the distraction gap
• In adult
– Interposition bone grafting is usually required

22. Metacarpal Distraction lengthening
• Traumatic MCP level thumb
amputation
– Covered in a groin flap
• Metacarpal corticotomy
• Distraction fixator to lengthen
the metacarpal
• Interpositional bone grafting
• A: Distractor applied.
• B: After lengthening.
• C: Bone graft placement.

23. Thumb lengthening
Options for lengthening a partial or distal subtotal thumb amputation
with the least donor-site morbidity include (A) osteoplastic reconstruction, (B)
phalangization, and (C) metacarpal distraction lengthening.

24. On-Top Plasty
• Best Indication/Unique Advantages
– Amputation in the area of the MCP joint is an
indication for this procedure, which will enhance the
value of a damaged finger
• Disadvantages and Special Requirements
– The appropriate finger is infrequently available, and
this procedure narrows the palm
– Transferred injured parts carry a higher risk of a
complication

25. On-Top Plasty
• Neurovascular pedicle transfer of the distal segment of a
damaged finger to lengthen the thumb.
• Removed by ray resection maybe needed.
• Pre-op arteriography may be helpful.
long thenal thumb and middle finger ray resection

26. Pollicization
• Best Indication/Unique Advantages
– The best indication is proximal subtotal or total
amputation.
– This procedure is the only satisfactory means of
basal joint reconstruction and results in
extensive physiologic sensory restoration.
• Disadvantages and Special Requirements
– This procedure narrows the palm.

27. Pollicization
• Pollicization refers to the neurovascular pedicle movement of a finger,
often with its metacarpal
– For congenital absence of the thumb
– The index finger is resected at the second metacarpal base
– Pronated : 130 degrees and projected in palmar abduction at its fixed base
– Dorsal or palmar skin into a web between middle finger and new thumb
– Extensor tendons must always be shortened as part of the primary procedure
– Flexor tendons follow a circuitous route, and length adjustments
– Structures receive new identities:
• EDC  APL
• EIP  EPL
• First dorsal interosseous  APB
• First palmar interosseous  adductor pollicis
• Metacarpal head and the proximal and middle phalanges  trapezium and the
metacarpal and proximal phalanges, respectively

28. Pollicization
• Preservation of intact
nerves for critical sensibility
• Secondary surgery will be
needed for approximately
50% of patients undergoing
pollicization, yet in the
right circumstances and for
the right indication, results
will be superior to that of
all other available
alternatives.

29. Toe-to-Thumb
• Best Indication/Unique Advantages
– Performed when most of a well controlled first
metacarpal is present but length is needed
– Advantages include
• (a) Good level of sensory recovery
• (b) Bone growth continues
• (c) Single-stage operation
• Disadvantages and Special Requirements
– Foot disability may occur
– Thumb always looks like a toe

30. Toe-to-Thumb
• Skin deficit on the hand
– Recipient site has skin grafts or
tight scars
– Adequate soft tissue prior to
the transfer operation
• Pre-op arteriography of the
hand and foot recommended
• Skeletal reconstruction for
correct length is tailored to
match the defect.
– Second toe transfers favored
for children
– Great toe transfers favored for
adults

31. Toe-to-Thumb
• Toe-to-thumb operations
– One or two teams.
– Level of toe osteotomy  lengths of skin, tendons, nerves, and vessels
– Recipient vessels explored first  define donor pedicle length.
– The radial artery is preferred.
– A racquet-shaped incision, which gives more dorsal than plantar skin.
– Veins are dissected first, elevating thin skin flaps proximally
– The dorsalis pedis and first dorsal metatarsal artery are dissected
– The plantar digital nerves are small and short compared to those of
the thumb
– Tendons are severed proximally to allow tendon repairs

32. Toe-to-Thumb
• Normal MTPJ range of motion is hyperextended relative to the
thumb MCPJ.
• If the MTPJ is included in the reconstruction
– Oblique metatarsal osteotomy used to increase flexion for more
natural thumb function.
• Although the reconstructed thumb is usually pronated
– the degree is determined for each case to function best with
remaining fingers.
• If opponensplasty is needed
– performed as a primary or secondary procedure.
• Second toe donor sites closed primarily
– facilitated by resection of the second metatarsal.
• Great toe donor-site closure often requires a skin graft.
• Donor-site morbidity is small, but cannot be dismissed entirely

33. Wraparound Toe Transfer
• Best Indication/Unique Advantages
– For amputation near the MCP joint or distal to it, this
is the procedure of choice.
– It results in the most normal-appearing reconstruction
from the foot.
• Disadvantages and Special Requirements
– This technically complex and demanding procedure
results in limited functional improvement when used
without an MCP joint.
– It requires an iliac bone graft.

34. Wraparound Toe Transfer
• Wraparound toe transfer
– Hybrid of great toe transfer and osteoplastic reconstruction
– Great toe is filleted
– The isolated free flap
• Distal half of the distal phalanx with the plantar, lateral, dorsal tissues, and toenail.
– This complex is wrapped around a bone graft
– The donor-site defect is closed
– The ultimate fingernail is narrowed
– No tendon repairs.
Modified wraparound great
toe transfer for a degloving
injury

36. 3-Q 4 Ur -- Attention !