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10.4 Reconstruction ofType IV Defect oftheThumb
155
Fig. 10.21 The proper extensor tendon of index nger and exor digitorum supercialis of the ring nger are used to reconstruct the exor and
extensor function of the reconstructed thumb
blood circulation of the reconstructed nger is observed, and
then the incision should be closed directly. In the donor site,
the stump of the second metatarsal can be further removed
according to the situation. The medial tissues of the rst
metatarsal and the lateral tissues of the 3–5 metatarsal can be
pulled to the center to suture the transverse metatarsal ligament as far as possible. The rst-stage direct suture or free
skin graft is used to close the wound.
and shortening the operation time, and the palm ap is not
fat, which needs not to be thinned in second stage, that is
satised in clinic; (b) Type IV defect of the thumb accompanied by skin defect of the web could be reconstructed by the
second toe combined with the metatarsophalangeal joint and
dorsal foot ap transplantation. If there is no skin defect at
the stump, V-shaped skin is still removed to prevent gooseneck deformity; (c) The rst metacarpal head and part of the
rst metacarpal should still be excised in the cases of com-
Postoperative Treatment
After the operation, lie in bed for 7 days, continued lamp
irradiation, the blood supply of the reconstructed nger, routine 3 antitherapy, dressing change every 2–3 days, and
suture removal 2 weeks later were observed.
plete capsule retained to avoid the method of the articular
surface connected with the proximal phalangeal articular
surface and suture capsule to repair; (d) The application of
this surgical method is relatively limited, which is only applicable to some special types of hand trauma with thumb
defect, and the donor site is damaged greatly.
10.4.4 Operation Characteristics
10.4.5 Announcements
(a) The second toe with dorsal ap transplantation is two ap
of single pedicle to repair palmar defect and reconstruct
thumb at the same time, avoiding the risk of two composite
aps transplantation, and broadening the surgical method
(a) Preoperative Doppler and CTA should be used to examine the dorsal artery of foot and the rst dorsal metatarsal
artery to determine the vascular course and no variation; (b)
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10 Reconstruction ofThumb Defects
Fig. 10.22 Reconstruction of Type IV defect of the right thumb by
free second toe transplantation. (a) Preoperative condition of thumb
defect. (b) Preoperative design. (c) The survived reconstructed thumb 6
weeks after the operation. (d) The dorsal view of the reconstructed
Complete debridement during operation is an important
factor to ensure the success of the operation; (c) The shape of
dorsal foot ap should be designed according to the defect of
the hand, and the blood supply of the ap needs to be paid
attention to; (d) When the rst dorsal metatarsal artery is
Gilbert III, the toe should be cut by the dorsal artery of footdeep plantar branch-rst plantar metatarsal artery, or the
“second blood supply system” and the deep plantar branch is
anastomosed with the plantar digital artery of foot or the
proper digital artery of foot; (e) The operation should be ne
and gentle, pulling the blood vessels should be avoided, and
vasospasm should be prevented; (f) The blood supply of the
reconstructed nger should be closely observed after the
operation, and timely treatment should be carried out in case
of vascular crisis.
10.4.6 Case Description
Case 1 A 16-year-old male patient was admitted to hospital
for 2 months after debridement and covered with aps due to
the right thumb defect caused by grass trimmer injury.
Physical examination: She was in good general condition,
thumb 3 months after the operation. (e) The palmar view of the reconstructed thumb 8 months after the operation. (f) Holding function of the
reconstructed thumb 3 months after the operation
with stable vital signs, loss of the right thumb from the metacarpophalangeal joint, and covered with ap. After admission, routine preoperative preparation for reconstruction was
given. The thumb was reconstructed by free second toe transplantation of the left foot under general anesthesia selectively and the donor site was sutured directly. The operation
was successful and routine reconstruction treatment was
given after the operation. Six weeks after the operation, the
reconstructed nger survived successfully. Regular follow up was conducted to guide functional exercise. The
appearance and function of the reconstructed nger were satisfactory (Fig.10.22).
Case 2 A 25-year-old female patient was admitted to hospital
in emergency for 3h due to pain and bleeding of the right
thumb caused by printing press crushing. Physical examination: She was in good general condition, with stable vital
signs, traumatic loss of the right thumb from the proximal segment, comminuted fractures, and loss of soft tissue. The other
ngers were normal. Debridement and stump repair were performed in emergency, and the wound healed well before she
was discharged. One month later, the patient returned to the
hospital for reexamination and was admitted to hospital again
10.4 Reconstruction ofType IV Defect oftheThumb
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157
Fig. 10.23 Reconstruction of type IV defect of the right thumb by free
second toe transplantation. (a) Preoperative dorsal condition of thumb
defect. (b) Preoperative palmar condition of thumb defect. (c)
due to requiring nger reconstruction. After admission, routine preoperative preparation for reconstruction was given.
The thumb was reconstructed by free second toe transplantation of the left foot under general anesthesia selectively and
the donor site was sutured directly. The operation was successful, after the tourniquet relaxed, the reconstructed nger was
ruddy with moderate tension, wrapped with the sterile cotton,
bulked, and stuffed with the broken cotton gauze around, and
she returned to the ward safely. Routine reconstruction treatment was given after the operation (Fig.10.23).
Case 3 A 27-year-old female patient was admitted to hospital in emergency for 4h due to pain and bleeding of the left
thumb caused by machine. Physical examination: She was in
good general condition, with stable vital signs, traumatic
loss of the left thumb from the metacarpophalangeal joint,
exposed bone fracture and tendons, irregular skin of the
stump, active bleeding, and the other ngers were normal.
Debridement and stump repair were performed in emergency, and the wound healed well before she was discharged.
Seven weeks later, the patient returned to the hospital for
reexamination and was admitted to hospital again due to
requiring nger reconstruction. After admission, routine pre-
Preoperative design. (d
deep plantar branch-dorsal artery of foot. (e) Cutting of the second toe.
(f) The thumb reconstruction by free second toe transplantation
) Dissociation of rst dorsal metatarsal artery-
operative preparation for reconstruction was given. The
thumb was reconstructed by free second toe transplantation
of the right foot under general anesthesia selectively and the
donor site was sutured directly. The operation was successful, after the tourniquet relaxed, the reconstructed nger was
ruddy with moderate tension, wrapped with the sterile cotton, bulked, and stuffed with the broken cotton gauze around,
and she returned to the ward safely. Routine reconstruction
treatment was given after the operation. Regular follow-up
was conducted to guide functional exercise. The appearance
and function of the reconstructed nger were satisfactory.
The donor site healed in the rst stage, and the patient was
satised with the appearance and function (Fig.10.24).
Case 4 A 30-year-old female patient was admitted to hospital in emergency for 6h due to pain and bleeding of the
left thumb caused by the machine. Physical examination:
she was in good general condition, with stable vital signs,
traumatic loss of the left thumb from the metacarpophalangeal joint, exposed bone fracture and tendons, irregular
skin of the stump, active bleeding, and the other ngers
were normal. The thumb was reconstructed by free second
toe transplantation of the right foot under general anesthe-
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10 Reconstruction ofThumb Defects
Fig. 10.24 Reconstruction of type IV defect of the left thumb by free
second toe transplantation. (a) Preoperative condition of thumb defect.
(b) Preoperative design. (c) Cutting of the second toe. (d) Thumb
reconstruction by free second toe transplantation. (e) The palmar view
of the reconstructed thumb 10 months after the operation. (f) The dorsal
sia in emergency and the donor site was sutured directly.
The operation was successful, after the tourniquet relaxed,
the reconstructed nger was ruddy with moderate tension,
wrapped with the sterile cotton, bulked, and stuffed with
the broken cotton gauze around, and she returned to the
ward safely. Routine reconstruction treatment was given
after the operation. One month after the operation, the
reconstructed nger survived successfully. Thirteen
months’ regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed nger were satisfactory. The donor site healed in
the rst stage, and the patient was satised with the appearance and function (Fig.10.25).
view of the reconstructed thumb 8 months after the operation. (g)
Holding function of the reconstructed thumb 10 months after the operation. (h) Opponens function of the reconstructed thumb 10 months after
the operation. (i) The situation of the donor site 10 months after the
operation
Case 5 A 30-year-old male patient was admitted to hospital
for 6 months after stump repair operation in outer hospital
due to the right thumb defect caused by the machine. Physical
examination: The right thumb totally missed and the wound
healed well. The other ngers were normal. After admission,
routine preoperative preparation for reconstruction was given,
and surgical contraindications were excluded. The thumb was
reconstructed by free second toe transplantation of the left
foot under general anesthesia selectively. The operation was
successful, after the tourniquet relaxed, the reconstructed nger was ruddy with moderate tension, wrapped with the sterile cotton, bulked, and stuffed with the broken cotton gauze
around, and she returned to the ward safely with plaster exter-
10.4 Reconstruction ofType IV Defect oftheThumb
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Fig. 10.25 Reconstruction of type IV defect of the left thumb by free
second toe transplantation. (a) Preoperative condition of thumb defect.
(b) Preoperative condition of thumb defect. (c) Dissociation of the second toe. (d) Cutting of the second toe. (e) Cutting of the second toe. (f)
Debridement of the recipient site. (g) The radial view of the reconstructed thumb 1 month after the operation. (h) The dorsal view of the
nal xation. After the operation, the patient was ordered to lie
in bed absolutely, the nger was irradiated with a roasting
lamp, and blood supply was observed. At the same time, routine triple antitreatment was given. No vascular crisis occurred
reconstructed thumb 1 month after the operation. (i) The situation of the
donor site 13 months after the operation. (j) The dorsal view of the
reconstructed thumb 13 months after the operation. (k) The palmar
view of the reconstructed thumb 13 months after the operation. (l)
Holding function of the reconstructed thumb 8 months after the
operation
after the operation, and the reconstructed nger successfully
survived. Regular follow- up was conducted to guide functional exercise. The appearance and function of the reconstructed nger were satisfactory (Fig.10.26).
160
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10 Reconstruction ofThumb Defects
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ghi
Fig. 10.26 Reconstruction of type IV defect of the right thumb by free
second toe transplantation. (a) Preoperative dorsal condition of thumb
defect. (b) Preoperative palmar condition of thumb defect. (c)
Preoperative X-ray. (d) Preoperative design. (e) Dissociation of the sec-
ond toe. (f) The reconstructed thumb 1 week after the operation. (g) The
reconstructed thumb 1 week after the operation. (h) The dorsal view of
the reconstructed thumb 3 weeks after the operation. (i) The palmar
view of the reconstructed thumb 3 weeks after the operation
f
Case 6 A 32-year-old female patient was admitted to hospital for 2 weeks after stump repair operation in outer hospital due to the left thumb defect caused by sawing machine
injury. Physical examination: The left thumb totally missed
and the wound healed well. After admission, routine preoperative preparation for reconstruction was given, and surgical contraindications were excluded. The thumb was
reconstructed by free second toe transplantation of the right
foot under general anesthesia selectively. The operation was
successful, after the tourniquet relaxed, the reconstructed
nger was ruddy with moderate tension, wrapped with the
sterile cotton, bulked, and stuffed with the broken cotton
gauze around, and she returned to the ward safely with plaster external xation. After the operation, the patient was
ordered to lie in bed absolutely, the nger was irradiated
with a roasting lamp, and blood supply was observed. At the
same time, routine triple antitreatment was given. No vascular crisis occurred after the operation, and the reconstructed
nger successfully survived. Regular follow-up was conducted to guide functional exercise. The appearance and
function of the reconstructed nger were satisfactory
(Fig.10.27).
10.4 Reconstruction ofType IV Defect oftheThumb
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Fig. 10.27 Reconstruction of type IV defect of the left thumb by free
second toe transplantation. (a) Preoperative dorsal condition of thumb
defect. (b) Preoperative palmar condition of thumb defect. (c)
Preoperative design. (d) Dissociation of the blood vessels and nerves in
the donor site. (e) Dissociation of the second toe. (f) The dorsal wound
in the donor site covered by skin graft. (g) The plantar wound was
sutured directly. (h) The appearance of the reconstructed thumb 2 years
after the operation. (i) Opponens function of the reconstructed thumb 2
years after the operation. (j) Holding function of the reconstructed
thumb 2 years after the operation. (k) The appearance of the donor site
2 years after the operation
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10.5 Reconstruction ofType V Defect
oftheThumb
This type thumb defect is located in the rst metacarpal
bone, which is often accompanied by skin defect, web contracture, and thenar injury. Due to the complete loss of part
of the metacarpal bone and the total thumb, about 40% of the
hand function would be lost, which would affect the daily
life of patients, and surgical reconstruction is the best indication. The second toe of the opposite foot transplantation
combined with the dorsal ap and the metatarsophalangeal
joint is the rst choice for reconstruction, and combined with
the forefoot ap could also be another choice.
According to the defect location of the metacarpal, it can
be divided into three subtypes: type I: located in the head of
the metacarpal, type II: located in the middle of the metacarpal; and type III: located in the proximal base of the
metacarpal.
10.5.1 Indications
10 Reconstruction ofThumb Defects
(1) Adult, young, and middle-aged is better; (2) The severed
thumb cannot be replanted; (3) The patient has a strong
desire for reconstruction, and no basic disease, peripheral
vascular disease; (4) No mental disease; (5) There is no history of trauma, surgery or infection in the donor toe and the
appearance is normal.
10.5.2 Surgical Design
Type V defect of the thumb is often accompanied by skin and
soft tissue defect and contracture of the web, etc. Preoperative
design needs to adopt the corresponding form of second toe
transplantation with dorsal skin ap for reconstruction and
repair according to different defects.
Incision Design in the Recipient Site One cup-shaped Y
incision should be designed on the radial side of the second
metacarpal, the mouth to distal, Y base tip to the proximal
lengthened longitudinal incision.
The U-shaped opening is located proximal to the second
metacarpophalangeal joint and is about 3 cm wide
(Fig.10.28).
Incision design in the donor site With the contralateral
second metatarsophalangeal joint as the center, triangular
incisions should be made on both sides of the rst and second toe web, making them connected in a diamond shape,
with the distal and proximal angles of about 120°, and the
length of the sides of about 3–4cm. The proximal incisions
extend in an “S” shape, and the plantar incisions are in a V
shape (Fig.10.29).
Fig. 10.28 The cup-shaped Y incision in the recipient site
10.5.3 Surgical Method
Preparation fortheRecipient Site
The length of the thumb defect, the size and range of the soft
tissue defect and the residual function of the thumb should
be measured preoperatively. Intraoperative debridement
should be performed to remove all necrotic tissue, trim the
bone stump, and protect the residual function. Radial artery
and accompanying vein, cephalic vein, supercial branch of
radial nerve, and proper digital nerve should be exposed for
use (Fig.10.30).
The Cutting oftheToe
Several issues should be noted during the operation: (a)
When the second toe is removed, the perforator branch of
dorsal artery of foot should be protected; (b) When the exor
tendon and plantar digital nerve are cut, they should be kept
as long as possible to prevent insufcient length in transplantation; (c) The transverse ligament of the metatarsal bone
must be repaired to reduce the functional damage of the foot;
(d) When the ap and the second toe are removed, the peritendon tissue should be protected. If the tendons and bones
are exposed, local or free ap should be applied (Figs.10.31
and 10.32).
10.5 Reconstruction ofType V Defect oftheThumb
Fig. 10.29 The incisions in
the donor site
163
Fig. 10.30 Lift the lingual ap and trim the bone stump Fig. 10.31 The incisions in the donor site
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Fig. 10.32 Dissociation of the second toe with dorsal ap
Transplantation
The bone should be xed with Kirschner wire or cross steel
wire, and the extensor tendon is sutured with “8” method,
and the exor tendon is sutured with modied Kessler.
Anastomosis of plantar digital nerve to proper digital nerve,
dorsal artery of foot to radial artery, great saphenous vein to
cephalic vein, and the accompanying veins should be performed under microscope. The suture tension of the ap
should not be large. If the exor pollicis longus tendon is too
short or not found, it can be repaired by transposition of
supercial exor tendon of the ring nger.
Postoperative Treatment
(a) Postoperative heat preservation, nursing should be
strengthened; (b) Postoperative antispasticity and anticoagulation therapy should be performed, and anti-infection
therapy should be added to those with wounds; (c) Absolute
bed rest for 7 days after the operation; (d) Smoking is prohibited during the perioperative period. Dressings are
10 Reconstruction ofThumb Defects
changed every 2–3 days and stitches are removed 2 weeks
after the operation.
10.5.4 Operation Characteristics
(a) Type V defect of the thumb is often accompanied by soft
tissue defect, which requires careful preoperative evaluation and
accurate design of the second toe skin ap; (b) Various forms of
dorsal foot ap, plantar-side V-shaped ap, and lingual ap on
the rst web space of hand should be reasonably adjusted
between the three aps to make full use of the effective area of
these skin not only to form the rst web space but also to eliminate the wound, and the excess skin should be excised; (c) Do
not damage the vascular pedicle of donor toe; (d) The injury is
large to the donor foot; when the wound is closed, we must be
careful to avoid causing hallux valgus deformity.
10.5.5 Announcements
(a) Preoperative planning is very important, which must be
designed in advance. A full preoperative evaluation can be
made to design a reasonable and effective composite dorsal
foot ap. A relative longer second metatarsal bone needs to
be removed, which may affect the foot function, that means
this operation should be carefully considered for those with
high functional requirements of the foot; (b) During the dissociation of the toe, the movements should be gentle, so as
not to pull and damage the vascular pedicle which would
reduce the spasm after vascular anastomosis; (c) The plantar
digital nerve and the proper digital nerve should be anastomosed as far as possible to restore and reconstruct the palmar
sensation of the nger; (d) After the anastomosis of the
reconstructed toe is completed, the bleeding must be stopped
completely to avoid the occurrence of postoperative hematoma; (e) The release of the extensor and exor tendons in
the recipient site must be complete, and the muscles must
have elastic retraction when pulled passively; (f) The reconstruction of the rst web space of hand should make full use
of the composite ap carried by the donor toe, and attention
should be paid to the incision location of the U-shaped skin
ap in the hand. Free skin graft can be considered if there is
a large area of scar on the wound surface; (g) The closure of
the foot wound must be paid attention to. During the operation, the surrounding aponeurosis should be protected. The
hemostasis should be completely stopped. When the wound
cannot be sutured directly, attention should be paid to the
tightness when applying free skin graft, and the blood circulation of the foot should be observed after the operation; (h)
Postoperative environment of patients should pay attention
to heat preservation, keeping quiet, no smoking, and the
patients should absolutely lie in bed for a week.
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