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11.5 Reconstruction ofType V Defect
195
ab
de
Fig. 11.17 Reconstruction of type V defect of the right index nger by
the free second toe transplantation. (a) Preoperative dorsal condition of
the nger defect. (b) Preoperative palmar condition of the nger defect.
(c) Remove the second toe. (d) Palmar view of the reconstructed nger
6 months after the operation. (e) Dorsal view of the reconstructed nger
6 months after the operation
c
index nger destroyed from middle plane of the proximal
interphalangeal and the stump healed well. The index nger
was reconstructed by the left second toe transplantation
under general anesthesia electively, 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, and the reconstructed nger survived successfully. The efcacy was satisfactory and the
donor site healed in rst stage (Fig.11.17).
Case 2 A 26-year-old female patient was admitted to hospital in emergency for 3h due to pain and bleeding of the right
middle, ring and little ngers defect caused by injection
molding machine crush injury. Physical examination: She
was in good general condition, with stable vital signs, type V
defect of the right middle, ring and little ngers, irregular
skin of the stump, exposed bone, active bleeding, seriously
polluted. After admission, routine preoperative preparation
for reconstruction was given, and surgical contraindications
were excluded. After complete debridement, the middle and
ring ngers were reconstructed by the bilateral second toes
transplantation and the little nger was performed stump
repair under general anesthesia in emergency, and the donor
site was sutured directly. The operation was successful; after
the tourniquet relaxed, the reconstructed ngers were 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, and the reconstructed
ngers survived successfully. The efcacy was satisfactory
(Fig.11.18).
196
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11 Reconstruction ofSingle Finger Defects
ab c
de f
gh i
jkl
mn o
pqr
Fig. 11.18 Reconstruction of type V defect of the right middle and
ring ngers by the free second toes transplantation. (a) Preoperative
palmar condition of the ngers defect. (b) Preoperative dorsal condition of the ngers defect. (c) Preoperative X-ray. (d) Preoperative
design (dorsal side). (e) Preoperative design (plantar side). (f)
Preoperative design. (g) Phalanx formation with free iliac bone. (h)
Dissociation of the medial plantar ap. (i) Transposition of the medial
plantar ap. (j) Transposition of the medial plantar ap to repair the
little nger. (k) Direct suture of the ap donor site. (l) Condition of the
donor sites. (m) Palmar view of the reconstructed ngers 60 months
after the operation. (n) Dorsal view of the reconstructed ngers 60
months after the operation. (o) Lateral view of the reconstructed ngers 60 months after the operation. (p) Function of the reconstructed
ngers 60 months after the operation. (q) Situation of the donor sites
60 months after the operation. (r) Situation of the donor site of the
medial plantar side of the right foot
11.6 Reconstruction ofType VI Defect
197
11.6 Reconstruction ofType VI Defect
Type VI defect is the absence of metacarpophalangeal joint
area, and its reconstruction effect is relatively poor. Whether
to reconstruct is still controversial. The reasons are many: the
movement direction of the metatarsophalangeal joint and
metacarpophalangeal joint are not consistent; the toes are
signicantly shorter than the ngers; the cutting of metatarsal bone may affect the function of the foot; the malfunction
of the reconstructed ngers may affect the function of the
normal ngers; and the difference of appearance is great.
11.6.1 Indications
(1) Type VI effect of the nger; (2) The patient is young and
has a strong desire for reconstruction.
11.6.2 Surgical Design
The ipsilateral second toe is cut off to carry the metatarsophalangeal joint and part of the metatarsal bone. Whether to carry the
dorsal ap is decided by the condition of the residual nger.
11.6.3 Surgical Method
Preparation fortheRecipient Site
Preoperative accurate measurement of the length of the nger
defect, whether there is soft tissue defect and the range.
Complete debridement should be performed during the operation to remove all necrotic tissue and trim the metacarpal
stump. If the second or third nger is reconstructed, the radial
artery and accompanying veins, cephalic vein, supercial
branch of radial nerve, and proper nerve should be exposed for
use. If the fourth or fth nger is reconstructed, the ulnar artery
and accompanying vein, dorsal vein of hand, dorsal branch of
the ulnar nerve, and proper nerve should be exposed for use.
The Cutting oftheToe
If the second or third nger is reconstructed, the ipsilateral
second toe is removed. If the fourth or fth nger is reconstructed, the contralateral second toe is removed. The method
is the same as before.
Transplantation
The wound surface of the transplanted toe is repaired to
make the length and size appropriate. Kirschner wires with a
diameter of 0.8–1.0 mm are used for crossover and
longitudinal xation, or steel wires with a diameter of
0.4mm are used for crossover xation. The extensor tendon
is sutured with nylon thread in gure 8 method. Modied
Kessler suture is used to suture the exor digitorum profundus tendon. Under microscope, anastomosis is performed on
bilateral proper nerves, veins, and arteries.
Postoperative Treatment
(a) Postoperative intensive nursing and heat preservation; (b)
Blood volume should be maintained and “three anti” therapy
is performed; (c) Do not get out of bed within 1 week after
the operation; (d) Smoking is prohibited during the perioperative period.
11.6.4 Operation Characteristics
The proximal segment of the nger is longer, type VI defect
refers to a larger range, higher functional requirements,
reconstruction of the nger both in terms of length, or the
number of joints are more complex, and the difculty is relatively higher.
11.6.5 Announcements
(a) Because of the difference in the distribution of blood
vessels and nerves between ngers and toes, the blood vessels and nerves in donor and recipient sites should be kept
to a certain length to facilitate the matching of the anastomotic site; (b) Most of the blood vessels are small and
require higher microscopic technique; (c) Most exor digitorum profundus tendons are obviously retracted during
elective operation, requiring longer exor digitorum tendons or tendon transposition; (d) There are obvious differences in the shape of toes and ngers; (e) Previous
satisfaction rate is low which needs to explain to the patient
in detail.
11.6.6 Case Description
Case 1 A 36-year-old female patient was admitted to hospital in emergency for 2.5h due to pain and bleeding of the
second to fth ngers defect caused by injection molding
machine crush injury. Physical examination: She was in
good general condition, with stable vital signs, type VI
defect of the right second to fth ngers, irregular skin of
the stump, exposed bone, active bleeding, seriously polluted. After admission, routine preoperative preparation for
reconstruction was given, and surgical contraindications
were excluded. After complete debridement, the index nger was reconstructed by the right second toe transplantation and forearm dorso-ulnar ap was designed and repaired
the rest defect under general anesthesia in emergency, and
the donor site was sutured directly. The operation was successful; after the tourniquet relaxed, the reconstructed ngers were 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, and
the reconstructed nger survived successfully. The efcacy
was satisfactory (Fig.11.19).
198
no
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11 Reconstruction ofSingle Finger Defects
ab c
d e f
g h i
jkl
m
pq r
Fig. 11.19 Reconstruction of type VI defect of the right index nger
by the free second toe transplantation. (a) Preoperative palmar condition of the ngers defect. (b) Preoperative dorsal condition of the ngers defect. (c) Preoperative design (dorsal side). (d) Preoperative
design of the ap. (e) Preoperative design (plantar side). (f) Dissociation
of the toe. (g) Phalanx formation with free iliac bone. (h) Design of the
forearm dorso-ulnar ap. (i) Dissociation of the forearm dorso-ulnar
ap. (j) Transposition of the forearm dorso-ulnar ap. (k) Skin graft in
the donor site of the forearm dorso-ulnar ap. (l) Condition of the donor
foot. (m) Condition of the donor foot. (n) Palmar view of the reconstructed ngers 24 months after the operation. (o) Dorsal view of the
reconstructed nger 24 months after the operation. (p) Flexor function
of the reconstructed nger 24 months after the operation. (q) Holding
function of the reconstructed nger 24 months after the operation. (r)
Holding function of the reconstructed nger 24 months after the
operation
Reconstruction ofMulti-Finger Defects
12
Abstract
Multiple nger reconstruction is the operation refers to
two or more ngers defect caused by a variety of reasons
in people’s daily life. In order to maximize the recovery of
the function and appearance of the injured hand, doctors
use microscopes and microsurgical instruments to carry
out vascular, nerve anastomosis, and other operations on
the patient’s own toe transplantation to reconstruct and
restore the original tissue anatomical structure and
function.
Reconstruction of multi-nger defects is still a difcult
point in hand surgery, and its treatment is controversial.
Two key issues need to be considered: First, the reconstruction of partial function of the hand and second, avoid
damage to foot function. The aim of the reconstruction of
multi-nger defect should be to reconstruct the pinching
function, and not to pursue the quantity and ideal appearance of the reconstructed nger. The more proximal the
plane of toe transplantation and the greater the number of
toe grafts, the greater the inuence on the function of the
foot, which requires careful selection. The classic method
of reconstruction of two ngers with the second toe of
both feet and tissue ap in this chapter, which can not
only rebuild part of the hand function, but also have little
effect on the function of the donor site.
12.2 Surgical Design
The aim of the reconstruction scheme is to rebuild the function of the hand and reduce the damage to the function of the
donor foot. The principle should be “less but better” instead
of “more and better”. In the case of 1–5 ngers defect, except
the thumb, the middle nger or ring nger is usually selected
as the another reconstructed nger; if 2–5 ngers defect is in
the same plane, the middle and ring ngers should be reconstructed; The index, middle nger or ring and little nger
defect can be reconstructed at the same time; type VI nger
defect, resulting in any 2–3 ngers defects, is not recommended for reconstruction. If 2–5 ngers defected at the
same time, only the second toe with metatarsophalangeal
joint should be selected for reconstruction of 1–2 ngers,
while the second and third toes with metatarsophalangeal
joint should not be cut at the same time for reconstruction.
From a functional point of view, the donor toe should be
placed on the nger where the metacarpophalangeal joint is
residual, which can prevent excessive toe cutting.
12.3 Surgical Method
12.3.1 Preparation fortheRecipientSite
Keywords
Finger reconstruction · Multi-nger defect
12.1 Indications
(a) Multi-nger defect, but the condition of nerves, blood vessels, and forearm muscle is good; (b) the patient is young who
has a strong desire for reconstruction and a psychological recognition of the appearance of the reconstructed ngers; (c)
the appearance and function of the donor toes are complete.
© Springer Nature Singapore Pte Ltd. 2023
J. Lin et al., Atlas of Finger Reconstruction, https://doi.org/10.1007/978-981-19-9612-2_12
For multi-nger reconstruction operation, the injury of the
donor site should be minimized to prevent the damage of
the foot function and avoid affecting the walking function.
A complete debridement should be performed on the
affected hand and ngers, that the extensor and exor tendons, digital nerves, and the blood vessels should be dissociated, respectively. The phalanx plane should be
trimmed. The condition of the blood vessels in the recipient
site after debridement should be judged, at the same time
the required length, diameter, and subcutaneous path of the
blood vessels for anastomosis should be conrmed. Two
arteries and two to four veins should be prepared for each
199
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12 Reconstruction ofMulti-Finger Defects
reconstructed nger. In the dissociation of the donor toe
and tissue ap, sharp separation of neurovascular bundles
and tendons is used to avoid carrying too much unneeded
soft tissue. Pay attention to protect the intermetatarsal ligament and the treatment of nerve stump; for patients with
dorsal foot wounds, full thickness skin grafts or aps
should be used as far as possible to minimize damage to the
donor site.
12.3.2 The Cutting oftheToe
According to the needs of the wound in the recipient site to
choose whether to carry dorsal foot ap. Design the incisions along the bilateral second toe; rst of all dissociate
foot vein from distal to proximal, then cut off and ligate the
unrelated veins of the second toe, but keep the continuity of
the dorsal vein of the second toe, dorsal metatarsal vein,
dorsal venous arc of foot, and great saphenous vein, cut off
and ligate the unrelated branches of great saphenous vein
until the ankle. When carrying dorsal ap dissociate the
artery from distal to proximal. The dorsal artery of foot
could be found between the extensor hallucis longus tendon
and the extensor digitorum longus tendon, along which cut
open the tube sheath and cut off the extensor hallucis longus tendon, along the way, to cut off and ligate the anterior
lateral malleolus artery, the anterior medial malleolus
artery, the lateral tarsal artery, and the medial tarsal artery.
The companying vein of the deep plantar branch should be
carefully dissociated and ligated. The rst dorsal metatarsal
artery, the common digital artery of toe, the tibial dorsal
digital artery, and the plantar digital artery of the second toe
are dissociated. The other branches of the rst dorsal metatarsal artery dividing into the tibial side of the second toe
should be reserved to ensure sufcient blood supply for the
second toe. When the “V-shaped” plantar ap is lifted, the
plantar digital nerve of the second toe could be found on
both sides, along which the common nerves of the rst and
second toe should be carefully and bluntly dissociated, that
is cut off at a high position and marked. If the dorsal ap is
not needed, the common digital nerve and artery, the tibial
dorsal digital nerve, and the plantar digital nerve and artery
can be dissociated directly at the webs on both sides of the
second toe. The extensor longus and brevis tendons of the
second toe should be sharply separated at the dorsum of the
foot and are cut off at a high position, at the same time
some peri-tendon tissues are retained. The exor digitorum
tendon sheath is cut open, and the exor digitorum longus
tendon and exor digitorum brevis tendon should be cut at
a high position according to the residual condition of exor
digital tendons in the recipient site. Then remove the toe in
different plane according to the length of the reconstructed
nger.
12.3.3 Transplantation
Internal xation with Kirschner wire is used for bone xation of the reconstructed nger. If the metatarsophalangeal
joint is needed to be carried, the plantar plate should be
sutured with the periosteum to prevent hyperextension of the
metatarsophalangeal joint. During bone and joint xation,
the opponens function of the reconstructed thumb should be
paid attention to before xation. The extensor and exor tendons are repaired with 2/0 nylon single thread. Adjust the
tension of extensor and exor tendons to prevent the exion
deformity of the reconstructed nger. Two exor tendons
would be sutured to the insertion of the lumbrical muscle of
the second toe to reconstruct the function of the lumbrical
muscle. The blood vessels and nerves are anastomosed under
a microscope.
12.3.4 Postoperative Treatment
(a) The operation of multi-nger reconstruction takes a longer time and has greater trauma, so the whole body condition
and vital signs should keep stable after the operation; (b)
Postoperative routine heat preservation and “three anti”
treatment should be carried out; (c) In addition to reasonable
immobilization after surgery, physical therapy should be carried out as soon as possible, that could be supplemented by
functional rehabilitation exercise, to promote subsidence of
swelling and prevent tendon adhesion and joint rigidity.
12.4 Operation Characteristics
The characteristics of operative methods are exible, and
individual treatment plan needs to be formulated according
to the actual conditions of each patient.
12.4.1 Announcements
(a) Close postoperative observation, timely treatment of vascular crisis; (b) Preoperative routine imaging examinations
should be used to examine the caliber, depth, and hemodynamic indexes of dorsal artery of foot and the rst dorsal
metatarsal artery, to help design the surgical plan and guide
the intraoperative operation; (c) For elective surgery cases,
the operation must be performed after the hand swelling has
subsided, so as to avoid vascular pedicle compression caused
by postoperative swelling; (d) Non-invasive operation to
avoid vascular pedicle injury; (e) The blood supply of foot
tissue aps is independent to avoid chain reaction after vascular crisis. High-quality vascular anastomosis is required;
(f) Pay attention to postoperative rehabilitation.
12.4 Operation Characteristics
201
12.4.2 Case Description
Case 1 A 39-year-old male patient was admitted to hospital
for more than 2 months due to the second to fth ngers
defect of the left hand caused by the machine injury. Physical
examination: He was in good general condition, with stable
vital signs, the second to fth ngers defect from the metacarpophalangeal joints. The index nger and the middle nger were reconstructed by the left second and third toes
transplantation electively and the donor site was sutured
directly. The operation was successful; after the tourniquet
was relaxed, the reconstructed ngers were ruddy with moderate tension, wrapped with the sterile cotton, bulked and
stuffed with the broken cotton gauze around, and he returned
to the ward safely. Routine reconstruction treatment was
given after the operation, and the reconstructed ngers survived successfully. The efcacy was satisfactory (Fig.12.1).
Case 2 A 43-year-old male patient was admitted to hospital
in emergency for 1.5 h due to pain and bleeding of the right
rst to fth ngers defect caused by injection molding
machine crush injury. Physical examination: He was in good
general condition, with stable vital signs, type IV defect of
the thumb and type V defect of the second to fth ngers,
irregular skin of the stump, exposed bone, active bleeding,
seriously polluted. After admission, routine preoperative
preparation for reconstruction was given, and surgical contraindications were excluded. After complete debridement,
the thumb was reconstructed by the left great toe nail ap
and the middle and ring ngers were reconstructed by the
free right second and third toes transplantation under general
anesthesia in emergency, and the donor site was sutured
directly. The operation was successful; after the tourniquet
was relaxed, the reconstructed ngers were ruddy with moderate tension, wrapped with the sterile cotton, bulked and
stuffed with the broken cotton gauze around, and he returned
to the ward safely. Routine reconstruction treatment was
given after the operation, and the reconstructed nger survived successfully. The efcacy was satisfactory (Fig.12.2).
Case 3 A 23-year-old male patient was admitted to hospital in
emergency for 1 h due to pain and bleeding of the right index
and middle ngers defect caused by punch press injury. Physical
examination: She was in good general condition, with stable
vital signs, type V defect of the index and middle ngers, irregular skin of the stump, exposed bone, active bleeding, seriously
polluted. After admission, routine preoperative preparation for
reconstruction was given, and surgical contraindications were
excluded. After complete debridement, the index and middle
ngers were reconstructed by the bilateral second toes transplantation under general anesthesia in emergency, and the donor
sites were sutured directly. The operation was successful; after
the tourniquet was relaxed, the reconstructed ngers were ruddy
with moderate tension, wrapped with the sterile cotton, bulked
and stuffed with the broken cotton gauze around, and he returned
to the ward safely. Routine reconstruction treatment was given
after the operation, and the reconstructed nger survived successfully. The efcacy was satisfactory (Fig.12.3).
abc
d
Fig. 12.1 Reconstruction of the left index and middle ngers by the
free second and third toes transplantation. (a) Preoperative condition of
the ngers defect. (b) Preoperative condition of the ngers defect. (c)
e
Preoperative design. (d) Remove the toes. (e) The condition of the
reconstructed ngers. (f) The condition of the donor site
f
202
ab
c
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12 Reconstruction ofMulti-Finger Defects
d
e
g
h
jk
f
i
l
m
Fig. 12.2 Reconstruction of the right middle and ring ngers by the
free second and third toes transplantation. (a) Preoperative palmar condition of the ngers defect. (b) Preoperative dorsal condition of the ngers defect. (c) Preoperative X-ray. (d) Preoperative design (dorsal
side). (e) Preoperative design (plantar side). (f) Dissociation of the toes.
(g) Palmar view of the reconstructed ngers. (h) Dorsal view of the
reconstructed ngers. (i) Palmar view of the reconstructed ngers 3
n o
years after the operation. (j) Dorsal view of the reconstructed ngers 3
years after the operation. (k) View of the rst nger web 3 years after
the operation. (l) Holding function of the reconstructed ngers 3 years
after the operation. (m) Study function of the reconstructed ngers 3
years after the operation. (n) Appearance of the left donor site 3 years
after the operation. (o) Appearance of the right donor site 3 years after
the operation
12.4 Operation Characteristics
a b c
203
d
g
e
h
jkl
f
i
m n
Fig. 12.3 Reconstruction of the right index and middle ngers by the
free bilateral second toes transplantation. (a) Preoperative condition of
the ngers defect. (b) Preoperative X-ray. (c) Preoperative design (dorsal side). (d) Preoperative design (plantar side). (e) Dissociation of the
right second toe. (f) Dissociation of the left second toe. (g) Palmar view
of the reconstructed ngers after the operation. (h) Dorsal view of the
reconstructed ngers after the operation. (i) Palmar view of the recon-
o
structed ngers 2 years after the operation. (j) Dorsal view of the reconstructed ngers 2 years after the operation. (k) Holding function of the
reconstructed index nger 2 years after the operation. (l) Holding function of the reconstructed middle nger 2 years after the operation. (m)
Dorsal view of the donor sites 2 years after the operation. (n) Plantar
view of the donor sites 2 years after the operation. (o) Appearance of the
donor sites and recipient sites 2 years after the operation
Reconstruction ofFinger Joint Defects
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13
Abstract
Hand joint injury is a common injury type while its clinical treatment has always been one of the difcult problems in hand surgery, and is also a more intractable
problem in repair and reconstruction surgery. There are
options for joint fusion and articial joint replacement to
repair the damaged joints, but the effect is not very ideal.
Among the joints of the hand, the range of motion of
metacarpophalangeal joints has the greatest inuence on
the hand function, and the proximal interphalangeal joints
of the second to fth ngers are also the main mobile
joints of the hand. After joint injury, if arthrodesis is performed, part of the function of the hand will be certainly
lost, resulting in poor strength, range of motion, and joint
stability of the injured nger. In recent years, according to
different types of nger joint injury, tissue homology, and
functional similarity, different methods of second toe
transplantation connected with interphalangeal joint have
been used to treat nger joint defect while its clinical feasibility and effectiveness have been explored. Single nger joint reconstruction is most common in clinic.
The single nger joint defect caused by various reasons is common that would lose exion and extension
function of the nger, which affects the play of hand function. Interphalangeal joint transplantation is a special
application of toe transplantation, which ts the principle
of supplying the shortage. At present, the most common
method is to reconstruct the nger joint defect by transplanting the proximal interphalangeal joint of the second
toe.
Keywords
Finger reconstruction · nger joint defect
13.1 Indications
(a) Partial or total interphalangeal joint defect of hand; (b)
single nger joint damage caused by various diseases; (c) the
patient is young who has no vascular disease and has high
requirement of hand function; (d) the length of the nger is
seriously shortened after the interphalangeal joint is fused
and the effect is not good; (f) there is no obvious deformity
of the donor toe.
13.2 Surgical Design
Surgical design follows the principle of supplying the shortage. The length of the nger joint defect and the size of the
combined defect of the nger should be carefully measured
before operation, and the range of the donor toe should be
accurately designed.
13.3 Surgical Method
13.3.1 Preparation fortheRecipientSite
The wound in the recipient site should be debrided completely to remove necrotic, seriously polluted, and inactivated tissues. Try to preserve as much skin and soft tissue as
possible to make the appearance full and close to the original
after repair. For all those hemiarticular defects, the residual
articular surface should be nibbled away to prepare for total
joint graft. The blood vessels, nerves, and tendons of the nger should be dissociated and marked for later use. To evaluate the blood supply status of the distal part of the nger and
© Springer Nature Singapore Pte Ltd. 2023
J. Lin et al., Atlas of Finger Reconstruction, https://doi.org/10.1007/978-981-19-9612-2_13
205
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