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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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10.3 Reconstruction ofType III Defect oftheThumb
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145
Fig. 10.11 Reconstruction of type II defect of the left 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 vascular pedicle. (e)
Dissociation of the bular ap of the great toe to repair stenosis. (f)
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. After 3 months’ follow-up, 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.10.11).
10.3 Reconstruction ofType III Defect
oftheThumb
Type III defect of thumb is located in the proximal phalange,
there are only two segments of phalanges, and the proximal
segment is longer; the loss of thumb function would be about
60–90%. The need for residual function and reconstruction
varies with the degree of defect. For the defect located distal
Thumb reconstruction by free second toe transplantation. (g) The pal-
mar view of the reconstructed thumb 3 months after the operation. (h)
The dorsal view of the reconstructed thumb 3 months after the opera-
tion. (i) Opponens function of the reconstructed thumb 3 months after
the operation
to the proximal phalange, about 80% loss of thumb function
and about 30% loss of hand function, which should be recon-
structed. Due to the retention of metacarpophalangeal joint,
the function is mostly satisfactory. The contralateral second
toe transplantation reconstruction is the best indication,
which could preserve exion and extension function of the
reconstructed thumb, it is the preferred surgical method for
this type of defect.
10.3.1 Indications
(1) Adult, young, and middle-aged is better; (2) A severed
thumb that cannot be replanted; (3) The patient has a strong
desire for reconstruction, whose general conditions are good,
and without systemic organic disease; (4) No basic disease,
mental disease, peripheral vascular disease; (5) Type III
defect of thumb; (6) There is no history of trauma, surgery,
or infection in the donor toe and the appearance is normal.
146
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10 Reconstruction ofThumb Defects
10.3.2 Surgical Design
According to the defect of the thumb, the second contralateral toe is designed to reconstruct the length and appearance
of the thumb, as well as the exion and extension function.
1. Incision design in the recipient site: Depending on the
thumb stump, a dorsal volar V-shaped or coronal incision
can be made (Fig.10.1). If a V-shaped incision is used,
the two upper ends are located on the upper edge of the
ulnar and radial sides of the thumb end, and the lower end
of V is a triangle. The purpose of the V-shaped incision is
to remove the V-shaped skin on the dorsal side of the nger and suture it with the skin on both sides of the reconstructed toe after the skin is fully released to avoid
gooseneck deformity. If the stump is coronal scar shape,
the original scar should be cut along to facilitate the
appearance. A longitudinal incision is made in the snuffbox to expose the cephalic vein and dorsal branch of the
radial artery. In case of emergency reconstruction, complete debridement should be performed in the thumb
stump wound, the contused skin and soft tissue should be
retained according to the condition.
2. Incision design in the donor site: According to the defect
of the thumb, the required length of the reconstructed
nger, and the shape and length of the second toe, a
V-shaped incision is made at the dorsal metatarsal at the
proximal part (Fig. 11.1), and the V-shaped incision
should be slightly larger than the V-shaped size of the
recipient site. An arc extension incision is made at the
proximal end of the V-shaped tip of the dorsal foot to
dissociate the dorsal artery of foot and the great saphenous vein bundle.
10.3.3 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.
tissue of the stump should be removed, and the broken bone
should be treated with fresh treatment. Proximal exor digi-
torum profundus should be explored and marked, and bilat-
eral proper digital arteries, nerves and veins should be
dissociated under microscope.
The Cutting oftheToe
The incision line is drawn on the donor toe according to the
shape and length of the thumb defect. The dorsal skin of the toe
is rst cut along the incision line to expose the vein, and two–
three dorsal digital veins of foot should be dissociated proxi-
mally to an appropriate length to be cut off. Then the plantar
skin is cut open, and one or two plantar digital veins of foot are
dissociated for use. The proper arteries, nerves, and exor digi-
torum profundus of foot are dissociated, and then cut off
according to the defect degree the ngers. The blood vessel
stump of the toe should be ligated, the toes are completely
amputated, and the toe stump is sutured and bandaged.
Transplantation
The wound surface of the transplanted toe should be repaired
to make the length and size appropriate. Kirschner wires
with a diameter of 0.8–1.0mm 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. The exor pollicis longus ten-
don is sutured by modied Kessler. Under the microscope,
anastomosis should be performed on toe-nger proper digi-
tal nerves, three–ve dorsal and palmar digital veins, and the
arteries on both sides.
Postoperative Treatment
(a) Postoperative heat preservation, strengthen nursing; (b)
Blood volume should maintained and “three anti” therapy
should be carried out; (c) Do not get out of bed within 1
week after the operation; (d) Smoking is prohibited during
the perioperative period.
10.3.4 Operation Characteristics
Preparation fortheRecipient Site
In case of emergency surgery, a complete debridement of the
injured nger is performed rst. The tendon of extensor digitorum, exor digitorum profundus, bilateral proper digital
nerves, and arteries, and 2–5 veins should be explored and
marked for use. Then debridement and irrigation should be
performed again under surgical microscope to make the
wound surface in the recipient site meet or close to the standard of class I incision. If it is a selected surgery, the scar
Type III defect of the thumb is the best indication for free
second toe transplantation. Since the proximal muscle group
of the thumb is intact and the metatarsal bone and transverse
ligament are not involved in the second toe transplantation, it
can not only reconstruct the shape and function of the thumb
but also cause little damage to the function of the foot. When
conditions permit, the gooseneck deformity of the recon-
structed nger can be repaired by the bular ap of the great
toe.
10.3 Reconstruction ofType III Defect oftheThumb
147
10.3.5 Announcements
(a) Preoperative design is very important. Individual design
should be carried out according to the defect condition of
the nger, which is not only benecial to the function and
beauty of the reconstructed nger, saving the operation
time, but also is helpful to reduce the injury of the donor
foot; (b) The donor toes should be without trauma history,
excessive small or deformity, and their appearance should
be as close as possible to the recipient site; (c) Emergency
doctors and anesthesiologists should have good communication, and patients should not use hemostasis and vasoconstrictor drugs before and during operation; (d) Detailed
menstrual history of female patients should be asked and
avoided; (e) Remove the V-shaped skin of the thumb stump
and release it to both sides. The excess skin must be cut off.
If the second toe is thin, the gooseneck deformity can be
repaired with the bular ap of the great toe; (f) The microcirculation of the reconstructed thumb and ngers should
be closely observed, so that timely detection and treatment
can be achieved; (g) After transplantation, the length should
not exceed 1/2 of the proximal segment of the index nger,
otherwise the appearance will be affected due to the excessive length of the reconstructed nger; (h) The secondstage plastic repair is needed in the patients with enlarged
abdomen of the second toe and the deformity of goose
neck.
10.3.6 Case Description
Case 1 A 22-year-old male patient was admitted to hospital
in emergency for 4h due to left thumb defect with pain and
bleeding caused by cutting machine injury. Physical exami-
nation: He was in good general condition, with stable vital
signs, traumatic loss of the distal segment of the left thumb,
irregular skin of the stump, exposed bone, active bleeding,
and the blood supply of the rest nger was normal. Successful
emergency debridement under general anesthesia was per-
formed. The patient was discharged after wound healing.
One month after the operation, the patient was admitted to
the hospital for thumb reconstruction and given preoperative
preparation for routine reconstruction. The right foot was
designed and the second toe was transplanted to reconstruct
the type III of the left thumb under general anesthesia 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 he returned to the ward
safely. Routine reconstruction treatment was given after the
operation and the reconstructed nger survived successfully.
Regular follow-up was conducted to guide functional exer-
cise. The appearance and function of the reconstructed nger
were satisfactory (Fig.10.12).
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Fig. 10.12 Reconstruction of type III defect of the left thumb by free
second toe transplantation. (a) Preoperative condition of thumb defect.
(b) Dessociation of the second toe according to the design. (c)
Dessociation of the dorsal metatarsal artery-deep plantar branch-dorsal
artery of foot system. (d) Dissociation of the vascular pedicle. (e)
Transplantation of the second toe; Radial palmar covered with skin
graft. (f) The appearance of the reconstructed thumb 10 months after
the operation
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10 Reconstruction ofThumb Defects
Fig. 10.13 Reconstruction of type III defect of the necrotic thumb
after replantation by free second toe transplantation. (a) Necrotic thumb
after replantation. (b) Preoperative design. (c) Reconstructed thumb.
(d) Appearance of the reconstructed thumb 13 months after the opera-
Case 2 A 19-year-old male patient was admitted to hospital for 3 days due to necrosis of the left thumb after replantation. Physical examination: He was in good general
condition, with stable vital signs, withered, and necrotic
nger body from the proximal segment. After admission,
routine preoperative preparation for reconstruction was
given. The thumb was reconstructed by free second toe
transplantation, 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, the reconstructed nger survived successfully. Regular follow-up was conducted to guide functional exercise. The appearance and function of the
tion. (e) Opponens function of the reconstructed thumb 13 months after
the operation. (f) Holding function of the reconstructed thumb 13
months after the operation
reconstructed nger were satisfactory 13 months after the
operation (Fig.10.13).
Case 3 An 18-year-old male patient was admitted to hospital
1 month after stumping wrapping for the right thumb and
index nger due to cutting injury. Physical examination: He
was in good general condition, with stable vital signs, type III
defect of the thumb, type VI defect of the index nger, and
type V defect of the middle nger. After admission, routine
preoperative preparation for reconstruction was given, and
surgical contraindications were excluded. The thumb was
reconstructed by free left second toe transplantation 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
10.3 Reconstruction ofType III Defect oftheThumb
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149
Fig. 10.14 Reconstruction of Type III defect of the right thumb by free
second toe transplantation. (a) Preoperative condition of thumb defect.
(b) Preoperative design. (c) Dissociation of blood vessels and nerves.
(d) Dissociation of the second toe. (e) The palmar view of the reconstructed thumb. (f) The dorsal view of the reconstructed thumb. (g) The
he returned to the ward safely. Routine reconstruction treatment was given after the operation and 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.10.14).
Case 4 A 22-year-old male patient was admitted to hospital 5 weeks after stumping wrapping for the right thumb
due to cutting injury. Physical examination: He was in good
palmar view of the reconstructed thumb 6 weeks after the operation. (h)
The dorsal view of the reconstructed thumb 6 weeks after the operation.
(i) Holding function of the reconstructed thumb 6 weeks after the
operation
general condition, with stable vital signs and type III defect
of the thumb. The thumb was reconstructed by free left sec-
ond toe transplantation and the donor site was sutured
directly at a selected time. Routine reconstruction treat-
ment was given after the operation and the reconstructed
nger survived successfully. Regular 10 months’ follow-up
was conducted to guide functional exercise. The appear-
ance and function of the reconstructed nger were satisfac-
tory (Fig.10.15).
150
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Fig. 10.15 Reconstruction of
type III defect of the right
thumb by free second toe
transplantation. (a)
Preoperative condition of
thumb defect. (b)
Preoperative design. (c) The
appearance of the
reconstructed thumb 10
months after the operation.
(d) Holding function of the
reconstructed thumb 10
months after the operation
10 Reconstruction ofThumb Defects
c
Case 5 A 20-year-old male patient was admitted to hospital
6 months after stumping wrapping in another hospital for the
left thumb due to machine injury. Physical examination: He
was in good general condition, with stable vital signs, total
thumb body defect, and wound healing. After admission,
routine preoperative preparation for reconstruction was
given, and surgical contraindications were excluded. The
thumb was reconstructed by free left second toe transplantation and the donor site was sutured directly 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 he returned to the
ward safely. 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 treatment 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.10.16).
Case 6 A 24-year-old male patient was admitted to hospi-
tal for 10 years due to deformity of the left thumb after
trauma. Physical examination: He was in good general con-
dition, with stable vital signs. The left thumb was smaller
and shorter than the healthy side. The exion of the inter-
phalangeal joint was limited. The peripheral blood supply
and sensation were available. After admission, routine pre-
operative preparation for reconstruction was given, and sur-
gical contraindications were excluded. The thumb was
reconstructed by free contralateral great toe ap transplan-
tation under general anesthesia at a selected time. The
deformed nger was truncated at the proximal segment of
the original nger. The operation was successful, 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 treatment
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.10.17).
d
10.3 Reconstruction ofType III Defect oftheThumb
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Fig. 10.16 Reconstruction of type III 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 X-ray. (d) Preoperative design. (e) Dissociation of the toe.
(f) The dorsal view of the reconstructed thumb 3 days after the operation. (g) The palmar view of the reconstructed thumb 3 days after the
k
operation. (h) The palmar view of the reconstructed thumb 4 months
after the operation. (i) The dorsal view of the reconstructed thumb 4
months after the operation. (j) Opponens function of the reconstructed
thumb 4 months after the operation. (k) Holding function of the recon-
structed thumb 4 months after the operation
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10 Reconstruction ofThumb Defects
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Fig. 10.17 Reconstruction of type III defect of the left thumb by free
contralateral great toe ap transplantation. (a) Preoperative appearance
of thumb defect. (b) Preoperative appearance of thumb defect. (c)
Preoperative design. (d) Dissociation of the ap. (e) Dissociation of the
ap. (f) The donor site after ap dissociation. (g) The donor site after
10.4 Reconstruction ofType IV Defect
oftheThumb
ap dissociation. (h) The recipient site. (i) The reconstructed thumb
after the operation. (j) The appearance and function of the reconstructed
thumb 6 months after the operation. (k) The appearance and function of
the reconstructed thumb 6 months after the operation. (l) The function
of the reconstructed thumb 6 months after the operation
with the volar lumbrical muscle of the second toe to restore
the opponens function. If the thumb stump is associated
with Dupuytren contracture, composite aps (such as dorType IV defect of thumb located in the rst metacarpophalangeal joint, because the thumb is completely missing, the
loss of hand function counts to 40%, which will cause seri-
sal foot aps) can be used for repair when the second toe
with metatarsophalangeal joint transplantation is used for
reconstruction.
ous impact on the daily life of patients and is the absolute
indication to choose reconstruction surgery. The second toe
with metatarsophalangeal joint transplantation is preferred.
10.4.1 Indications
Type IV defect of thumb is often accompanied by soft tissue defect which requires tissue transplantation with dorsal
ap. The opponens pollicis is intact which could be sutured
Type IV defect of thumb and the other indications are moder-
ate type III defect of thumb.
10.4 Reconstruction ofType IV Defect oftheThumb
153
10.4.2 Surgical Design
The reconstruction of thumb by free transplantation of toe
tissue with dorsal foot ap is based on the dorsal foot artery
and its continuation of the rst dorsal metatarsal artery. Due
to the limitation of the length of the vascular pedicle, there
are certain requirements for the wound surface: (a) The
defect is proximal to the metacarpophalangeal joint or avulsion injury of thumb; (b) Combined with the soft tissue
defect of the palm, with tendons and bones exposed, and the
repaired area is slightly smaller than that of the dorsal skin;
(c) No variation in dorsal artery of foot and rst dorsal metatarsal artery; (d) The vascular condition in the recipient site
is permissible.
The recipient site:
1. The stump without contracture scar can be longitudinal
sagittal plane either a V-shaped incision can be made
(Fig.10.18).
2. For patients with contracture of the web or scar on soft
tissue of the radial side, the scar tissue skin should be
completely removed with an arc, and the incision is usually designed with an “S” shaped (Fig.10.18).
In case of emergency reconstruction, the thumb stump
wound should be debrided thoroughly, and the contusion and
necrotic soft tissue should be completely removed.
The donor site:
If the soft tissue condition of the recipient site is good,
V-shaped incisions can be made on both the plantar and dor-
sal sides of the donor site (Fig.10.19). If the soft tissue condition is not good, the defect after scar resection can be
repaired by composite tissue ap of the foot dorsum according to its shape (Fig.10.20).
10.4.3 Surgical Method
General condition: The patient should be in good general
condition without contraindications related to surgery or
anesthesia, and the anesthesia is performed under brachial
plexus anesthesia plus epidural anesthesia or general anesthesia. The operation could be performed in two groups: the
recipient group and the donor group.
Preparation fortheRecipient Site
The length of the healthy thumb and the shape and size of the
soft tissue defect should be measured preoperatively. The
tendon of extensor digitorum and exor digitorum profundus
tendon should be explored and marked intraoperatively, and
bilateral proper digital nerves, arteries, and 2–5 veins should
be dissociated under a magnifying glass or microscope for
use.
The operation area is routinely disinfected, laid towel,
and the tourniquet on the recipient side is elevated after driving the blood. Firstly, the thumb stump incision should be
made according to the design, the skin and subcutaneous soft
tissue are cut (if there is scar, the scar tissue should be com-
Fig. 10.18 Routine incision for type IV defect of thumb
Fig. 10.19 The incision of the donor site when the soft tissue condi-
tion of the recipient site is good
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10 Reconstruction ofThumb Defects
Fig. 10.20 According to the different conditions of soft tissue defect in the recipient site, the ap could be designed exibly in the donor site
pletely removed), the rst metacarpal bone is fully extended
by free release, and the digital nerves are found and released
in the wound of the stump and marked. The exor pollicis
longus tendon, extensor pollicis longus tendon, and extensor
pollicis brevis tendon should be found and fully relaxed in
the palm and dorsal side, respectively. Abductor pollicis brevis should be exposed and completely released to recover the
elasticity; About 0.5–1cm of bone could be removed from
the metacarpal stump, and the incision is extended proximally or make a separate one at the snuffbox to expose the
cephalic vein and dorsal branch of the radial artery. If the
defect of extensor pollicis longus tendon, exor tendon, and
digital nerves is caused by retrograde avulsion, nerve and
tendon transplantation of adjacent nger can be used to
tissue condition after debridement of the wound in the recipient site, a V-shaped incision is made on the dorsal metacarpal
or corresponding to the defect in the recipient site according
to the design, the medial skin is cut open to nd the great
saphenous vein in the ap, and the unrelated branches should
be ligated. The excision of the exor and extensor tendons
and nerves of the second toe is similar to the excision of type
III defect of thumb. When the toe is completely dissociated
except for the vascular pedicle, the tourniquet should be
relaxed to observe the blood supply of the toe. Finally, the
second toe is dislocated, and the vascular pedicle is cut off
according to the required length and appropriate position of
the recipient blood vessels; the toe should be transplanted to
the recipient site.
reconstruct the extensor and sensory function. Extensor pollicis longus tendon could be repaired and reconstructed by
transposition of the proper extensor tendon of the index nger and transposition of exor digitorum supercialis of the
ring nger (Fig.10.21). The ulnar proper digital nerve of the
index nger could be transferred to reconstruct the ulnar sensory function of the toe (Fig.10.21).
Transplantation
The transplanted toe should be adjusted to make the length
and size suitable. The bone of the connected part of the bone
should be removed appropriately, and the ap is adjusted to
cover the wound without tension. Kirschner wires with
diameters of 0.8–1.0mm are used for crossover and vertical
xation, or wires with diameters of 0.4 mm are used for
The Cutting oftheToe
The second toe with dorsal ap should be designed according to the size and shape of the defect. According to the soft
crossover xation. The extensor tendon is sutured with nylon
thread. The exor tendon is sutured with modied Kessler.
Vessels and nerves are anastomosed under microscope. The
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