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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_801_Библиотеки_им_академика_М_И_Перельмана
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10.1 Reconstruction ofType IDefect oftheThumb
The Cutting oftheToe
(a) The cutting of part of the great toe: The surgical inci-
sion of great toe should be designed according to the
size of the healthy thumb. The tibial lingual ap and the
arteries and nerves under it should be reserved. The
proper digital nerves and arteries should be dissociated
to the desired length on the peroneal side. If necessary,
the rst dorsal metatarsal artery or the rst plantar
metatarsal artery could be reserved to make the length
of the vessel to be sufcient before pedicle amputation.
For nail skin ap of great toe, only ap tissue should be
removed. The donor site is directly sutured or covered
with skin grafts.
(b) The cutting of part of the second toe: According to the
required length of the reconstructed nger, an arcshaped transverse incision is made on the dorsal side
of the second toe, and an “S”-shaped longitudinal
additional incision is made to the proximal end. One
the dorsum of proximal segment. Additional incisions
to proximal at the midline of the both sides of the toe
are made to dissociate and mark the proper digital
nerves of foot. The proper tibial digital artery can be
dissociated and if it is necessary you can reach the rst
dorsal metatarsal artery or the rst plantar metatarsal
artery. The distal segment or interphalangeal joint
should be cut as required. For nail skin ap of great
toe, only ap tissue should be removed. The donor site
is directly sutured or covered with skin grafts
(Fig.10.3).
135
Fig. 10.4 After suturing the reconstructed nger
Fig. 10.3 Closure of wound in the donor site
Transplantation
(a) For partial great toe and second toe transplantation, a
single Kirschner wire is used to x the toe and nger bones
through. The dorsal digital vein of foot is led to the dorsum
of nger through subcutaneous tunnel, and one or two veins
are anastomosed with 11-0 or 12-0 nylon monolament
under the microscope, and then suture the skin; the proper
nerves should be anastomosed with 9-0 nylon monolament;
the digital arteries should be anastomosed with 12-0 with
nylon monolament and close the wound. (b) For nail skin
ap transplantation, the lateral wound of the ap should be
sutured rst, and then the bone should be. The vascular and
nerve anastomosis method is the same as before (Fig.10.4).
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) Blood supply
observation of reconstructed nger is recommended for 6h/
time, lasting for 1 week; (d) Two weeks after the operation,
the suture should be removed and function exercise should
be begun.
136
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10 Reconstruction ofThumb Defects
10.1.4 Operation Characteristics
(a) High level of microsurgical technique is required, especially anastomosis technique for the small vessel; (b)
Operation is performed under a magnifying glass or a
microscope, and usually requires special surgical instruments; (c) The operation is non-functional reconstruction,
usually should not be performed in emergency; (d) The
operation does not need to cut the metatarsal bone, which
would not affect foot loading and walking; (e) Only the phalanges part in the donor site required to be dissociated, and
the blood vessel anatomy is constant. It is not affected by
the variation of the rst dorsal metatarsal artery, and the
operation is simple; (f) The structure of the toes and ngers
is similar, the appearance of the reconstructed thumb is
good, which is close to the normal, and sometimes it can
achieve just-as- good effect; (g) It is easy to take samples,
the trauma of the donor site is small, which heals quickly,
and the patient has no pain when walking on the ground
after a week.
10.1.5 Announcements
(a) Young patients with good surgical tolerance and compliance should be selected, especially those with high requirements for the appearance and function of donor sites and
reconstructed ngers; (b) When transplanting great toenail
ap, pay attention to protect the donor site to ensure that the
wound can be directly sutured to embedded the bone, otherwise the phalange should be shortened; (c) The great toe size
ratio is different for each patient, and the size should be
designed according to the normal side; (d) Preoperative and
intraoperative hemostasis and vasoconstrictor drugs should
not be given to patients. All the patients who chose the distal
segment of great toe reconstruction should choose the same
side toe; (e) The design of the lingual ap on the tibial side
should be appropriate; (f) The enlarged part on both sides of
the base of the distal segment of great toe should be corrected appropriately. In addition, the hypertrophy of adipose
tissue at the toe base should be trimmed to make the tibial
side wound look like the thumb on the healthy side after
suturing; (g) During the dissociation of the toe, the movements should be gentle, so as not to pull and damage the
vascular pedicle, so as to reduce the occurrence of spasm
after vascular anastomosis; (h) After the anastomosis of the
reconstructed toe, the wound bleeding must be stopped completely to avoid the occurrence of postoperative hematoma;
(i) The free release of the extensor and exor tendons in the
recipient site must be complete, and the passive pulling muscles must have elastic retraction; (j) Postoperative bandaging
must be loose to prevent vascular crisis due to postoperative
swelling and over-tight bandaging of the reconstructed
nger.
10.1.6 Case Description
Case 1 Type I defect of the right thumb. A 33-year-old
female patient was admitted to hospital in emergency for
1 h due to ngertip defect caused by punching injury.
Physical examination: She was in good general condition,
with stable vital signs, a defect at the distal end of the right
thumb and an exposed fracture. After admission, routine
preoperative preparation for reconstruction was given, and
surgical contraindications were excluded. The thumb was
reconstructed by the great toe nail ap under general anesthesia in emergency, and the donor site was covered by free
full-thickness skin graft. 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 (Fig.10.5).
Case 2 Type I defect of the right thumb. A 29-year-old
female patient was admitted to hospital in emergency for
2 h due to pain and bleeding caused by the machine.
Physical examination: She was in good general condition,
with stable vital signs, traumatic loss of the distal segment
of the right thumb from the nail root, irregular skin of the
stump, exposed bone, active bleeding, and moderate pollution. After admission, the thumb stump was debrided under
brachial plexus anesthesia, the bone was smoothened, and
the dorsal metacarpal tendon and the ulnar proper neurovascular bundle were ready for disconnection. The thumb
was reconstructed by the ipsilateral great toe nail ap. 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. Routine reconstruction treatment was given after the operation. Two
weeks after the operation, the reconstructed nger survived
successfully. Regular follow-up was conducted to guide
functional exercise. The appearance and function of the
10.1 Reconstruction ofType IDefect oftheThumb
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Fig. 10.5 Reconstruction of type I defect of the right thumb. (a)
Preoperative palmar condition of thumb defect. (b) Preoperative dorsal
condition of thumb defect. (c) Preoperative design (dorsal side). (d)
Preoperative design (lateral side). (e) Preoperative design (plantar side).
(f) Dissociation of the ap. (g) Free left great toe composite tissue ap.
(h) Blood vessels and nerves. (i) Thumb reconstruction with free trans-
plantation. (j) The dorsal view of the reconstructed thumb 8 months
after the operation. (k) The palmar view of the reconstructed thumb 8
months after the operation. (l) Appearance contrast of the reconstructed
thumb. (m) Opponens function of the reconstructed thumb 8 months
after the operation. (n) The situation of the donor site 8 months after the
operation
138
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10 Reconstruction ofThumb Defects
Fig. 10.6 Reconstruction of type I defect of the right thumb by the
ipsilateral great toe nail skin ap. (a) Preoperative dorsal condition of
thumb defect, (b) Preoperative palmar condition of thumb defect. (c)
Design of the free great toe nail skin ap. (d) Design of the free great
reconstructed nger were satisfactory. The donor site
healed in the rst stage, and the patient was satised with
the appearance and function (Fig.10.6).
Case 3 Type I defect of the right thumb. A 31-year-old
female patient was admitted to hospital in emergency for 2h
due to pain and bleeding caused by the machine. Physical
examination: She was in good general condition, with stable
vital signs. The soft tissue distal to nail bed of the right thumb
was cotton like, the distal phalanx bone fractured, and the
nail bed was damaged, with part of the distal phalanx bone
toe nail skin ap. (e) Dissociation of the ap. (f) Transplant the ap. (g)
The appearance of the reconstructed nger. (h) Dorsal view of the
donor site. (i) Palmar view of the donor site
and soft tissue defect. The emergency operation was successful, and the incision was free of infection and necrosis 10
days after the operation. A further procedure of
“reconstruction of the defect of the end of the right thumb by
transplanting free great toenail skin ap combined with tibial
tissue ap of the second toe” was performed at a selected
time. 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
10.1 Reconstruction ofType IDefect oftheThumb
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139
Fig. 10.7 Reconstruction of type I defect of the right thumb by transplanting free great toenail skin ap combined with tibial tissue ap of
the second toe. (a) Type I defect of the right thumb. (b) Design of the
ap. (c) Design of the ap. (d) Dissociation of the ap. (e) The recon-
after the operation. Two 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.10.7).
Case 4 Type I defect of the right thumb. A 28-year-old
female patient was admitted to hospital for 5 days after
debridement. The distal segment of the right thumb was
defective. After debridement, the wound was sutured and
structed nger after the operation. (f) Appearance contrast of the reconstructed thumb. (g) The situation of the donor site. (h) The situation of
the donor site
scabbed. Blood circulation in the remaining ngers was normal. After admission, routine preoperative preparation for
reconstruction was given, free big toe to thumb reconstruction was performed at a selected time 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 sur-
140
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10 Reconstruction ofThumb Defects
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Fig. 10.8 Reconstruction of type I defect of the right thumb by free
great toe nail skin ap combined with bular side ap of great toe. (a)
Preoperative dorsal condition of thumb defect. (b) Preoperative lateral
condition of thumb defect. (c) Preoperative X-ray. (d) Preoperative
design. (e) Design of the bular ap of the thumb. (f) Dissociation of
vived successfully. After 1-year follow-up, the donor site and
reconstructed thumb are completely healed with excellent
function and appearance (Fig.10.8).
the vascular pedicle. (g) The dorsal view of the reconstructed thumb
after the operation. (h) The lateral view of the reconstructed thumb after
the operation. (i) Nail condition 1 year after the operation. (j) Finger
pulp condition 1 year after the operation. (k) X-ray 1 year after the
operation. (l) The situation of the donor site 1 year after the operation
the bacterial culture were negative, the left foot was designed
and transplanted the rst toenail ap compound ap under
general anesthesia to reconstruct the left thumb. The operation was successful, after the tourniquet relaxed, the recon-
structed nger was ruddy with moderate tension, wrapped
Case 5 A 34-year-old male patient was admitted to hospital
for non-healing of the wound 11 months after the operation
due to sh bone injury of the left thumb. Physical examination: She was in good general condition, with stable vital
signs. The nger tip of the left thumb was missing with
inammatory exudation. After three times debridement and
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 opera-
tion. After 4 months’ follow-up, the function and appearance
were excellent, and the donor site healed completely
(Fig.10.9).
10.1 Reconstruction ofType IDefect oftheThumb
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Fig. 10.9 Reconstruction of type I defect of the infected left thumb by
free great toe nail skin ap. (a) Preoperative palmar condition of thumb
defect. (b) Preoperative dorsal condition of thumb defect. (c) The defect
after debridement. (d) Preoperative design (dorsal side). (e) Preoperative
design (lateral side). (f) Preoperative design (plantar side). (g)
Dissociation of the ap. (h) Dissociation of the blood vessels and
nerves. (i) Dissociation of the ap. (j) Cover the recipient site with the
ap. (k) Cover the recipient site with the ap. (l) Suture the donor site
directly. (m) The palmar side of the reconstructed thumb 4 months after
the operation. (n) The dorsal side of the reconstructed thumb 4 months
after the operation. (o) The donor site healed 4 months after the
operation
142
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10 Reconstruction ofThumb Defects
10.2 Reconstruction ofType II Defect
oftheThumb
Type II defect is the defect at the interphalangeal joint of the
thumb, which is often caused by various injuries, leading to
50% loss of thumb function and 20% loss of the hand function, and there are denite indications of reconstruction.
Even most of the length of the thumb is preserved, with the
development of society and economy, people now pay more
and more attention to the pursuit of their own appearance
beauty on the basis of satisfying their material needs. More
and more patients require reconstruction and repair.
Considering the psychological, occupational, aesthetic and
social needs of patients, the distal segment of the thumb can
be reconstructed by anastomosing toe-nger arteriovenous
blood circulation, which can obtain satisfactory appearance
and function. In the donor site, great toe or the distal segment
of the second toe could be transplanted, great toe could be
transplanted for those with large stump, and the second toe
could be transplanted for those with small stump. When
selecting the distal segment of great toe, it is often necessary
to trim the larger condyles on both sides of the base of the
phalanx of the great toe.
10.2.1 Indications
(1) Adult, young, and middle-aged is better; (2) No basic disease; (3) No mental disease, peripheral vascular disease; (4)
Type II defect of thumb; (5) The patient has a strong desire
for reconstruction and the wound is clean and the surrounding tissues are free from infection; (6) There is no history of
trauma, surgery, or infection in the donor toe and the appearance is normal.
10.2.2 Surgical Design
The surgical design of type II defect of thumb is similar to
that of type I, transplantation of partial great toe and the terminal part of the second toe, which are commonly used.
10.2.3 Surgical Method
The patient should have complete preoperative examinations without contraindications to surgery and anesthesia,
and is carried out under general anesthesia in the operating
room.
Preparation fortheRecipient Site
For the defect of the distal segment of the thumb, a coronal
incision could be made at the stump to remove the scar and
lift the skin to the dorsal side. The proper digital nerves
should be marked on both sides and principal arteries of
thumb should be dissociated within the incision. An arc inci-
sion is made on the dorsal proximal segment to separate one
or two thicker dorsal phalanx veins for use. If it is an emer-
gency operation, the stump should be debrided completely to
remove the polluted and inactivated tissue, and then debrided
again under the operating microscope, and the proper digital
proper nerves and digital arteries should be marked. An arc
incision is made on the dorsal proximal segment to separate
one or two thicker dorsal phalanx veins for use.
The Cutting oftheToe
(a) The cutting of part of the great toe: The surgical inci-
sion of great toe should be designed according to the
size of the healthy thumb. The tibial lingual ap and the
arteries and nerves under it should be reserved. The
proper digital nerves and arteries should be dissociated
to the desired length on the peroneal side. If necessary,
the rst dorsal metatarsal artery or the rst plantar
metatarsal artery could be reserved to make the length
of the vessel to be sufcient before pedicle amputation.
For nail skin ap of great toe, only ap tissue should be
removed. The donor site is directly sutured or covered
with skin grafts.
(b) The cutting of part of the second toe: According to the
required length of the reconstructed nger, an arc-shaped
transverse incision is made on the dorsal side of the second toe, and an “S”-shaped longitudinal additional incision is made to the proximal end. One or two thicker
dorsal digital veins of foot should be dissociated to the
dorsum of proximal segment. Additional incisions to
proximal at the midline of the both sides of the toe are
made to dissociate and mark the proper digital nerves of
foot. The proper tibial digital artery can be dissociated
and if it is necessary you can reach the rst dorsal metatarsal artery or the rst plantar metatarsal artery. The
distal segment or interphalangeal joint should be cut as
required. For nail skin ap of great toe, only ap tissue
should be removed. The donor site is directly sutured or
covered with skin grafts (Fig.10.3).
10.2 Reconstruction ofType II Defect oftheThumb
143
Transplantation
(a) For partial great toe and second toe transplantation, a
single Kirschner wire is used to x the toe and nger bones
through. The dorsal digital vein of foot is led to the dorsum
of nger through subcutaneous tunnel, and one or two veins
are anastomosed with 11-0 or 12-0 nylon monolament
under the microscope, and then the skin should be sutured;
Anastomose the proper nerves with 9-0 nylon monolament; Anastomose the digital arteries with 12-0 with nylon
monolament and close the wound. (b) For nail skin ap
transplantation, the lateral wound of the ap should be
sutured rst, and then the bone should be covered. The vascular and nerve anastomosis method is the same as before
(Fig.10.4).
Postoperative Treatment
(a) Postoperative heat preservation, strengthen nursing; (b)
Postoperative antispasticity and anticoagulation therapy
should be performed, and anti-infection therapy should be
added to those with wounds; (c) Blood supply observation
of reconstructed nger is recommended for 6h/time, lasting for 1 week; (d) Two weeks after the operation, the
suture should be removed and function exercise should be
begun.
10.2.4 Operation Characteristics
(a) High level of microsurgical technique is required, especially anastomosis technique for the small vessel; (b)
Operation is performed under a magnifying glass or a microscope, and usually requires special surgical instruments; (c)
The operation is non-functional reconstruction, usually
should not be performed in emergency; (d) The operation
does not need to cut the metatarsal bone, which would not
affect foot loading and walking; (e) Only the phalanges part
in the donor site required to be dissociated, and the blood
vessel anatomy is constant. It is not affected by the variation
of the rst dorsal metatarsal artery, and the operation is simple; (f) The structure of the toes and ngers is similar, the
appearance of the reconstructed thumb is good, which is
close to the normal, and sometimes it can achieve just-asgood effect; (g) It is easy to take samples, the trauma of the
donor site is small, which heals quickly, and the patient has
no pain when walking on the ground after a week.
10.2.5 Announcements
(a) The amputated site of the transplanted toe is far away, and
the toe arteries and veins are thin, so it is easy to be damaged
during dissociation, especially the dorsal digital veins of
foot. Therefore, attention should be paid to protect the conti-
nuity of the vein network, and not to cut too much tissue to
avoid pressure in the tunnel; (b) The stump of the proper
arteries in the recipient site should be debrided to the normal
lumen to avoid postoperative embolization. The subcutane-
ous tunnel should be loose, so as to avoid venous distortion
and compression; (c) Skin margin suture should be smooth
and excess skin must be removed, so as to avoid the swollen
skin after healing, which would affect the appearance; (d)
Postoperative vascular crisis should be treated actively, but
not be long observation, so as not to delay the opportunity of
treatment.
10.2.6 Case Description
Case 1 A 27-year-old male patient was admitted to hospital
in emergency for 1.5h due to distal segment defect of the
right thumb with pain and bleeding caused by Injection
molding machine injury. Physical examination: He was in
good general condition, with stable vital signs, traumatic
loss of the distal segment of the right thumb from the inter-
phalangeal joint, exposed bone, tendons, irregular wound,
and active bleeding. There was skin contusion and laceration
at distal segment of the index nger, and blood circulation of
other ngers was normal. Emergency debridement under
general anesthesia was performed and the operation was suc-
cessful. One week after debridement, preoperative prepara-
tion for routine reconstruction was given. The left second toe
to thumb transplantation was designed and performed under
general anesthesia 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 he returned to the ward
safely. Routine reconstruction treatment was given after the
operation. Two weeks after the operation, the reconstructed
nger survived successfully. Regular follow-up was con-
ducted to guide functional exercise. The appearance and
function of the reconstructed nger were satisfactory. The
144
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10 Reconstruction ofThumb Defects
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Fig. 10.10 Reconstruction of Type II defect of the right thumb by free
second toe transplantation. (a) Preoperative palmar condition of thumb
defect. (b) Preoperative dorsal condition of thumb defect. (c)
Preoperative design. (d) Dissociation of the second toe. (e) The dorsal
view of the reconstructed thumb after the operation. (f) The palmar
view of the reconstructed thumb after the operation. (g) The palmar
donor site healed in the rst stage, and the patient was satised with the appearance and function (Fig.10.10).
Case 2 A 47-year-old male patient was admitted to hospital
in emergency for 0.5h due to distal segment defect of the left
thumb caused by machine punch injury. Physical examination: He was in good general condition, with stable vital signs,
traumatic loss of the distal segment of the left thumb from the
view of the reconstructed thumb 13 months after the operation. (h) The
dorsal view of the reconstructed thumb 13 months after the operation.
(i) Fisting function 13 months after the operation. (j) Flexion function
of the reconstructed thumb 13 months after the operation. (k) The dor-
sal view of the donor site 13 months after the operation. (l) The plantar
view of the donor site 13 months after the operation
interphalangeal joint, exposed bone, irregular wound, and
active bleeding. After admission, routine preoperative prepa-
ration for reconstruction was given, and surgical contraindica-
tions were excluded. The thumb was reconstructed by the right
second toe combined with the bular ap of the great toe free
transplantation under general anesthesia in emergency, and the
donor site was sutured directly combined with covered by free
full-thickness skin graft. The operation was successful, after
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