Free non vascularized toe phalangeal grafts

1. A Retrospective Review of the use of
Non Vascularized Free Toe Phalangeal
Grafts In the treatment of
Symbrachydactyly and Constriction
Ring Syndrome
Dr Steve Carter
Red Cross Childrens Hospital
Cape Town

2. The Goal in Congenital Aphalangism is to
achieve a hand with improved length, stability
and movement for prehension to occur

3. Classification Symbrachydactyly
Blauth

4. Introduction
• Optimal treatment of Congenital Aphangism is controversial
• Ranges from no treatment to complex microvascular transfers
• In between the above options are the use of Allografts , On Top Plasty ,
Distraction lengthening, Phalangilization
• Non Vascularized free Toe Phalangeal Transfer (NVFTPT) offers a simple,
reliable and effective means of achieving our goal

5. Biology
• Embryonic cartilagenous long bone precursor
• At 4 weeks in utero, nutrient artery supplies Primary ossification centre
• Secondary ossification center and epiphysis survive by diffusion of nutrients
until 3 years

6. History
• Carrol and Green 1975. 159 toe phalangeal grafts , No resorption but no
growth ( Harvested sub periosteally
• Buck-Gramcko 1990. 97 Grafts Emphasized extra periosteal harvesting
improved growth of bone
• Radocha 1993. 73 grafts Emphasized 1) age less than 1 year 2) periosteal
preservation 3) joint reconstruction
• More recent studies Lanz, 2005 (73 transfers) and Tonkin 2005 (22)
showing improved Physeal patency and growth

7. Indications
• Aphalangism (Symbrachydactyly)
• Adequate metacarpal development
• Adequate soft tissue coverage
• Appropriate age preferably less than 1 year
• Presence of a Phalanx for transfer XR
• Presence of flexors and extensors

8. Surgical Technique
Hand

9. Surgical Technique
Foot

10. Surgical Technique

11. Surgical Technique
Foot

12. Results
Patient DOB Surgery Timing Grafts Condition
1 Male 7/05/09 18/5/10 12mths 3 I M Th Symbrachy
2 Female 16/09/09 4/11/10 14mths 2 I M Symbrachy
3 Male 28/01/11 31/08/11 7mths 2 I Th Symbrachy
4 Male 27/09/06 15/08/07 11mths 2 I Th Symbrachy
5 Female 27/05/09 2/12/09 7mths 2 R L Symbrachy
6 Male 11mths 2 I Th Symbrachy
7 Female 12mths 2 M R Hemimelic
8 Male 14mths 2 I Th Hemimelic
9 Male 10mths 1 I Constriction

13. Results
• 6 Male and 3 Female Patients
• Total of 18 Free Non Vascularized Toe Phalangeal Grafts
• Average time to surgery was 10.8 Months
• Average number of grafts was 2
• Thumb and Index were the most commonly grafted
• 7 grafts to the Index
• 5 grafts to the Thumb
• 7 symbrachydactyly,2 hemimelic ,1 CCBS

14. Results
• Average follow up 2 years longest 6 years shortest 8 mths
• No patients showed any graft resorption
• All grafts were terminal grafts
• Physeal patency was 60%

15. Results
• No soft tissue complications or dehiscence
• One local dorsal rotation flap used for CCBS
• Feet No local complications all walking toes shorter but no deviation

16. Conclusion
• Free toe phalanx transfers offers a quick and simple method of
lengthening congenitally short digits.
• They are most suited for use in multidigit telescoping phalangeal
aplasias
• Reliable length a functioning joint and prehension are predictably
achieved
• Hand function is significantly improved
• Parental satisfaction is high