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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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17 Special Types ofFinger Reconstruction
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Fig. 17.3 Reconstruction of type IV defect of the right index nger in
a child by the free left second toe transplantation. (a) Preoperative palmar condition of the nger defect. (b) Preoperative dorsal condition of
the nger defect. (c) Preoperative design (dorsal side). (d) Preoperative
design (plantar side). (e) Dissociation of the second toe. (f) The dissociated toe. (g) The palmar view of the reconstructed nger after the operation. (h) The dorsal view of the reconstructed nger after the operation.
o
(i) The situation of the donor site after the operation. (j) The dorsal view
of the reconstructed nger 7 months after the operation. (k) The palmar
view of the reconstructed nger 7 months after the operation. (l) Extensor
function of the reconstructed nger 7 months after the operation. (m)
Opponens function of the reconstructed nger 7 months after the operation. (n) The dorsal view of the donor site 7 months after the operation.
(o) The plantar view of the donor site 7 months after the operation
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17.3 Reconstruction ofCongenital Deformity ofFingers
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Fig. 17.4 Reconstruction of type V defect of the left second to fth
ngers in a child by free bilateral second and third toes 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 (plantar side). (e) The palmar view of the
f
reconstructed ngers 10 months after the operation. (f) The dorsal view
of the reconstructed ngers 10 months after the operation. (g) Clamping
function of the reconstructed ngers 10 months after the operation. (h)
Opponens function of the reconstructed ngers 10 months after the
operation. (i) Life situation 10 months after the operation
17.3 Reconstruction ofCongenital
Deformity ofFingers
method to restore the appearance and function of the nger.
In addition, the acquired traumatic absence of the nger is
very common, and the technique of nger reconstruction
Finger dysplasia is a kind of congenital disease characterized
by short ngers. It is often accompanied by a shallower nger web and usually only involves the hands without obvious
heredity. The incidence rate is about 1: 32,000 to 1:40,000.
Blauth and Gekele classied the dysplasia of the nger into
four types: type I, brachydactylia; type II, split-hand/foot
with toe transplantation has been applied quite maturely. The
congenital digital deformity is relatively rare and has charac-
teristics different from acquired traumatic digital malforma-
tion. Only by mastering the characteristics of congenital
digital deformity, the best surgical treatment effect can be
obtained.
malformation; type III, ectrodactyly; type IV, acheiria. Type
I and II hands retain most of their functions, while type III
loses most of their functions, and type IV loses all their func-
17.3.1 Indications
tions. As long as at least two functional ngers are reconstructed for type III most of the lost function can be restored.
Therefore, the surgical treatment of type III is very necessary, and also very meaningful. Toe is the organ most similar
to the nger in appearance and function, so it is the best
(a) The patient is young and physically able to endure a long
operation; (b) For patients with higher requirements for n-
ger aesthetics; (c) The appearance and function of the donor’s
toe are normal.
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17 Special Types ofFinger Reconstruction
17.3.2 Surgical Design
(a) For congenital nger defect deformity, reconstruction of
the index and middle nger is the rst choice; (b) The
nerves, blood vessels, tendons, and internal muscles of the
affected hand are all dysplasia (the interosseous and lumbrical muscles are often decient); (c) The branches of the
median nerve and ulnar nerve in the palm are abnormal or
even defective, so the cutaneous branch of the dorsal radial
nerve of hand is needed to suture with the digital nerve of
the toe. Vessels are mainly artery malformation, dysplasia of
the wall, easy to spasm, vascular crisis after anastomosis,
thrombosis; (d) Flexor muscle exibility is poor, the exor
tendon is at and thin and its insertion point is wide which
often stops in the subcutaneous tissue of the distal palm,
while the extensor tendon is often well developed; (e) The
defect of the nger is usually manifested as a small skin tag
with sufcient skin and soft tissue; (f) There is no need to
carry too much skin or dorsal foot ap when taking the toe,
which is conducive to the closure of the wound surface of
the foot and has little damage to the appearance and function of the foot.
17.3.3 Operation Characteristics
(a) The second to fth ngers, only the proximal part of the
proximal phalanx has partial development and the base of the
articular surface is abnormal, while some even do not have
any phalanx existence, the remaining so-called ngers have
no functional role. The abnormal proximal phalanx is often
removed during the operation, but the capsule should be
retained; (b) The second to fth metacarpal head dysplasia is
serially severe, while the rst nger web is often normal. A
good metacarpophalangeal joint is the best guarantee of
good nger function.
The range of motion of the dorsal extension of the second
metatarsophalangeal joint is obviously larger than the range
of motion of the plantar- exion. When the thumb and meta-
carpophalangeal joint are reconstructed, the range of
motion should be adjusted appropriately according to the
healthy side. If you want to increase the metatarsophalan-
geal range of motion, rst extend the second metatarsopha-
langeal joint and then cross the string of Kirschner wires
longitudinally, x the metatarsophalangeal joint with the
metacarpophalangeal joint as an extension position, and
repair the joint shape appropriately.
17.3.5 Case Description
Case 1 The 22-year-old male patient was admitted to the
hospital for 10 years due to deformity and function limitation
of the right index and middle ngers caused by trauma.
Physical examination: He was in good general condition,
with stable vital signs, the index and middle ngers are
deformed with limited extension and exion. After admis-
sion, routine preoperative preparation for reconstruction was
given, and surgical contraindications were excluded. The n-
gers were reconstructed by the left second toe combined with
second metatarsophalangeal joint transplantation under gen-
eral anesthesia at a selected time, and the donor site was per-
formed stump repair. 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 he
returned to the ward safely. Routine reconstruction treatment
was given after the operation. Nine months after the opera-
tion, the reconstructed ngers survived successfully. Regular
follow-up was conducted to guide functional exercise. The
appearance and function of the reconstructed ngers were
satisfactory (Fig.17.5).
17.3.4 Announcements
(a) The reconstruction of the distal interphalangeal joint of
types II and III nger defect is of limited effect which
should be careful; (b) The diameter of the nger phalanx is
small. When cutting the toe, the dorsal part of the phalanx
should be cut according to the size of the nger phalanx,
and the plantar part could be kept intact to reduce the damage to the function and appearance of the toe. In order to
prevent the shrinkage of the reconstructed nger from
becoming small, the design of the reconstructed nger
should be about 1cm longer than the circumference of the
healthy nger; (c) The grafted joint should be nerved and
anastomosed with the sensory nerve of the recipient site to
reduce the occurrence of postoperative osteoarthritis; (d)
Case 2 The 25-year-old female patient was admitted to the
hospital for more than 25 years due to a congenital deformity
of the right thumb. Physical examination: She was in good
general condition, with stable vital signs, short and deformed
thumb, limitation of extension and exion, and reduced n-
ger web. After admission, routine preoperative preparation
for reconstruction was given, and surgical contraindications
were excluded. The nger and rst nger web were recon-
structed by the right great toenail ap combined with second
toe composite tissue ap transplantation under general anes-
thesia at a selected time, and the donor site was covered by
residual tissue complementary repair. 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
17.3 Reconstruction ofCongenital Deformity ofFingers
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Fig. 17.5 Reconstruction of the right index and middle ngers defect
deformity by free left second toe combined with second metatarsophalangeal joint transplantation. (a) Preoperative palmar view. (b)
Preoperative dorsal view. (c) Preoperative X-ray. (d) Preoperative
design (the recipient site). (e) Preoperative design (the donor site). (f)
The palmar view of the reconstructed ngers after the operation. (g)
The donor site covered by direct suture. (h) Postoperative X-ray. (i) The
palmar view of the reconstructed ngers 9 months after the operation.
(j) The dorsal view of the reconstructed ngers 9 months after the oper-
ation. (k) Holding function of the reconstructed ngers 9 months after
the operation. (l) Opponens function of the reconstructed ngers 9
months after the operation. (m) The dorsal view of the donor site 9
months after the operation. (n) The plantar view of the donor site 9
months after the operation
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17 Special Types ofFinger Reconstruction
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Fig. 17.6 Reconstruction of congenital deformity of the right thumb
by the right great toenail ap combined with second toe composite tissue ap transplantation. (a) Preoperative dorsal view. (b) Preoperative
palmar view. (c) Preoperative design. (d) Preoperative design. (e) The
dorsal view of the reconstructed nger and rst nger web after the
operation. (f) The palmar view of the reconstructed nger and rst nger web after the operation. (g) The palmar view of the reconstructed
reconstruction treatment was given after the operation.
Eighteen months after the operation, the reconstructed nger
survived successfully. Regular follow-up was conducted to
guide functional exercise. The appearance and function of
the reconstructed ngers were satisfactory (Fig.17.6).
nger 2 months after the operation. (h) The dorsal view of the recon-
structed nger 2 months after the operation. (i) The dorsal of the donor
site 2 months after the operation. (j) The plantar of the donor site 2
months after the operation. (k) The function of the reconstructed nger
18 months after the operation. (l) The function of the reconstructed n-
ger 18 months after the operation
Case 3 The 19-year-old female patient was admitted to the
hospital for more than 19 years due to a congenital deformity
of the right middle and ring ngers. Physical examination:
She was in good general condition, with stable vital signs.
The middle and distal segments of the middle nger were
17.3 Reconstruction ofCongenital Deformity ofFingers
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Fig. 17.7 Reconstruction of congenital deformity of the right middle
and ring ngers by the distal segment of the right second toe combined
with joint composite tissue ap transplantation. (a) Preoperative dorsal
view. (b) Dissociation of the ap. (c) The palmar view of the reconstructed ngers after the operation. (d) The palmar view of the reconstructed ngers 2 years after the operation. (e) Holding function of the
short, with contraction band deformity and limited extension
and exion function. The ring nger was short and deformed
with limited function. The ngers were reconstructed by the
distal segment of the right second toe combined with joint
composite tissue ap transplantation under general anesthesia
at a selected time, and the donor site was covered by residual
tissue complementary repair. The operation was successful,
after the tourniquet relaxed, the reconstructed nger was
reconstructed ngers 2 years after the operation. (f) Extensor function
of the reconstructed ngers 2 years after the operation. (g) Postoperative
X-ray. (h) The situation of the donor site 2 years after the operation. (i)
Working condition of the reconstructed ngers 2 years after the
operation
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 treat-
ment was given after the operation. Twenty-four months after
the operation, the reconstructed nger survived successfully.
Regular follow-up was conducted to guide functional exer-
cise. The appearance and function of the reconstructed ngers
were satisfactory (Fig.17.7).
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17 Special Types ofFinger Reconstruction
17.4 Reconstruction ofDegloving Defects
ofFingers
Degloving defect of nger is a kind of severe avulsion injury
of skin and soft tissue that is unconditional in situ repair.
This kind of injury is often accompanied by skin and soft
tissue degloving, tendon avulsion from muscle belly, the
plane of vein disjunction is mostly near the skin section, and
the artery and god are often extracted from the proximal end
of a certain length, especially the nerve is longer than the
artery, and the artery is often with a long segment of intima
injury in microscopic exploration. The injury mechanism
refers to the worker wearing gloves to operate the fastmoving machine or the ring wearer’s ring being violently
torn. When the nger is involved in the fast-moving machine,
the injured person tries to violently pull back, and the soft
tissue of the whole nger, including skin, subcutaneous tissue, blood vessels, and nerves, is torn off like a glove. Only
phalanges, joints, and extensor and exor tendons are left in
the residual nger, while in severe cases, distal phalanges
and extensor and exor tendons are torn off. Pedicle ap,
free ap or toenail ap, and free second toe transplantation
are often used to restore the function and appearance of
ngers.
17.4.1 Indications
(a) The patient is young and physically able to endure a long
operation; (b) For patients with higher requirements for nger aesthetics; (c) The appearance and function of the donor’s
toe are normal; (d) type I to type VI nger defect.
17.4.2 Surgical Design
The toenail ap of the rst toe with enough skin, the second
toe joint and its tendon system, and the free iliac bone fragment are cut and reassembled to reconstruct a nger with a
similar appearance to a normal nger. The distal interphalangeal joint is fused at an angle of about 30°. The toenail ap
of the rst toe and the joint tendon system of the second toe
is co-pedicled, and the blood supply is nourished by the rst
dorsal metatarsal vessels. For the foot donor site, a free graft
of iliac bone is taken to repair the bone defect, and a free
graft of groin ap is taken to repair the skin and soft tissue
defect.
17.4.3 Surgical Method
Preparation fortheRecipient Site
The size, scope, and characteristics of the defect should be
measured before operation. Complete debridement is per-
formed during the operation, the visible blood vessels and
nerves are exposed and protected under the microscope
which should not be easily ligated but marked for
anastomosis.
The Cutting oftheToe
(a) Reconstruction of Type I nger defect: First, the dorsal
digital vein of the great toe is dissociated on the dorsum
of the great toe and dissociated proximally to an appropriate length before being cut off, and then dissociated
along the vein branch to the bular end of the great toe
to the tip. The dorsal metatarsal artery and plantar metatarsal artery as well as the bular plantar digital artery of
the great toe emitted after anastomosis are dissociated at
the toe web. After dissociating the artery and nerve of
the bular plantar of the great toe, the transverse artery
is cut and ligated, and the nerve bundle of the artery and
nerve bundle is further dissociated distally to the proximal end of the ap. The skin is cut along the design line
in the toe pulp, and several supercial toe veins are carefully dissociated proximally for 1–2cm before being cut
off for use. The subcutaneous tissue of the toe pulp is
further cut deep to the bular side of the bone. Cut the
toenail on the tibial side and proximal side to the periosteum according to the design line. With a ne milling
drill cutting the dorsal side and tibial side of the bone, a
bone knife separates the bone cortex of the bular and
tibial sides, together with part of the toenail and the ap.
The plantar digital artery and nerve of the great toe
should be cut off at the appropriate length.
(b) Reconstruction of types II and III nger defect: The dor-
sal digital vein of the great toe is dissociated on the dorsum of the great toe and dissociated proximally to an
appropriate length before being cut off, and then dissociated along the vein branch to the bular end of the great
toe to the tip. The dorsal metatarsal artery and plantar
metatarsal artery as well as the bular plantar digital
artery of the great toe emitted after anastomosis are dissociated at the toe web. After dissociating the artery and
nerve of the bular plantar of the great toe, the transverse artery is cut and ligated. The skin is cut along the
design line in the toe pulp, and the ap is dissociated
17.4 Reconstruction ofDegloving Defects ofFingers
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263
subcutaneously to the bular side of the bone. According
to the design line, the tibial side of the toenail is cut to
the periosteum, and the dorsal bone cortex of the phalanx is cut with a milling cutter. The dorsal toe ap is
lifted distally from the surface of the periapendoneum to
the insertion point of the extensor digitorum longus tendon. A ne milling cutter is used to cut the dorsal phalangeal cortex and tibial cortex far from the extensor
longus tendon. The dorsal phalangeal cortex is separated
from the tibial plantar cortex with a bone knife, and part
of the toenails and the ap are dissociated together. The
bular plantar artery and nerve of the great toe should be
cut off at the appropriate place. The phalanges in the
composite tissue ap are trimmed, and the length is measured. If the length could not reach the required length of
the reconstructed nger, the iliac bone or allograft bone
should be taken for reserve. For those requiring repair of
the distal interphalangeal joint, the second interphalangeal joint is grafted.
(c) Reconstruction of type IV nger defect: The ap should
be removed through the designed incision at the great
toe and the second toe as the donor site. The dorsal metatarsal ap is cut open to expose the supercial dorsal
metatarsal vein and dissociated distally to the dorsum of
the great toe and second toe to nd the main supercial
veins as the return veins. Dissociate the deep peroneal
nerve, the rst dorsal metatarsal artery, the rst plantar
metatarsal artery, the bular proper plantar digital artery
and nerve of the great toe, and the tibial proper plantar
digital artery and nerve of the second toe. If the rst dorsal metatarsal artery is absent or thin, the longer plantar
metatarsal artery can be cut as a tissue ap artery. The
incision is extended to the dorsal side and the plantar
side, respectively, and the extensor longus tendon, deep
and supercial exor tendons of the second toe are dissociated. The length of the tendon is determined according to the condition of the recipient site. The toenail ap
is cut according to the designed width of the nail and
osteotomy is performed on the proximal end of the toenail root of the terminal tarsal toe, so that the phalanx of
the terminal toe can be attached to the toenail ap.
Then carefully dissociate and cut the composite tissue
ap of the proximal interphalangeal joint of the second
toe with the middle segment and the proximal phalangeal
bone. A suitability length iliac bone strip is cut behind the
anterior superior iliac spine 2 cm from the iliac crest.
Before suturing the skin, according to the condition of the
skin defect of the donor's foot, cut the appropriate size of
spindle-shaped strip along the incision, and then pull it
together to suture the wound. If a free inguinal ap is
required to repair a foot wound, dissociation of the ap
should be performed before the iliac crest is removed.
(d) Reconstruction of type V nger defect: The proximal
phalanx body is missing in type V nger defect. It is
necessary to take one more ilium bone and place it in the
position of the proximal phalanx to solve the problem of
the proximal phalanx defect.
(e) Reconstruction of type VI nger defect: On the basis of
the type IV defect, the ipsilateral or contralateral second
metatarsophalangeal joint is transplanted to reconstruct
the metacarpophalangeal joint.
(f) Treatment of donor's foot: For the case with four toes
retained, the residual toenail ap of the second toe can
be combined with the great toe stump and internal xation with Kirschner wire, and the skin is sutured. The
dorsal metatarsal wound could be covered by free aps
or a free skin graft. The donor site of the toe joint can be
lled with an iliac bone of the same size through
Kirschner wire xation. In the case of keeping ve toes,
foot ap or groin ap transplantation can be used to
repair the donor wound.
Transplantation
The great toenail skin is rolled into a tube and the proximal
interphalangeal joint of the second toe should be placed in an
appropriate position. The defect between the phalangeal
bone in the joint and the great toenail ap is lled with iliac
bone strips. A 1.0mm diameter Kirschner wire is used to
string the three together to form a new nger, which would
be transplanted to the stump of the nger to be reconstructed.
The great toenail ap can be transplanted with the second toe
joint in the same pedicle, or the tibial plantar digital artery of
the second toe can be cut off from the proximal starting
point, and then the plantar artery of the second toe and the
artery of the toenail ap can be anastomosed with the corresponding proximal proper digital artery respectively after
being wrapped. Suture the extensor and exor tendons with
tendon threads. If the great toenail ap is successfully
wrapped around the phalangeal artery without disconnection, the dorsal metatarsal artery (or plantar metatarsal
artery) can be anastomosed with the ipsilateral proper digital
artery or palmar digital artery of the reconstructed nger. If
the artery is disconnected, the bular plantar artery of the
great toe and the tibial plantar artery of the second great toe
264
17 Special Types ofFinger Reconstruction
can be anastomosed with the ipsilateral proper digital artery
of the reconstructed nger, respectively. Then the veins of
great toenail ap and the second toe are anastomosed with
the supercial subcutaneous veins of the dorsal hand. Finally,
the bular plantar nerve of great toe and the tibial plantar
nerve of the second great toe are anastomosed with corresponding proper digital nerves of the reconstructed nger.
Postoperative Treatment
(a) After the operation, intensive nursing and close observa-
tion of the reconstructed nger should be carried out.
(b) Routine treatment of "three antitherapy" after the
operation.
17.4.4 Operation Characteristics
(a) Repair skin soft tissue defect; (b) Repair nail bed defect
and rebuild nail function; (c) Rebuilt the good appearance.
17.4.5 Announcements
(a) Type II or Type III nger defects can be reconstructed by
transplantation of the bone, toenail, and skin composite
tissue of the bular dorsal side of the great toe. The skin
and toenail are sufcient, but the length of the toe bone
is limited. It is better to bridge a segment of the ilium if
it is not long enough.
(b) The effect of reconstruction of the distal interphalangeal
joint of type II or type III nger defect is limited we
should be careful.
(c) When cutting the toenail ap, do not separate the toenail
and nail bed, try not to separate the bone and nail bed, so
as not to affect the appearance of the reconstructed nail.
(d) The diameter of the nger phalanx is small. When cut-
ting the toe, the dorsal part of the phalanx should be cut
according to the size of the nger phalanx, and the plantar part could be kept intact to reduce the damage to the
function and appearance of the toe. The smaller toenail
ap can be wrapped by matching the phalangeal of the
nger with the smaller toe bone, reducing the design
area of the ap and reducing the impact on the donor's
toe.
(e) In order to prevent the shrinkage of the reconstructed
nger from becoming small, the design of the recon-
structed nger should be about 1cm longer than the circumference of the healthy nger, especially in the
reconstruction of the thumb.
(f) The grafted joint should be nerved and anastomosed
with the sensory nerve of the recipient site to reduce the
occurrence of postoperative osteoarthritis
(g) The range of motion of the dorsal extension of the sec-
ond metatarsophalangeal joint is obviously larger than
the range of motion of the plantar-exion. When the
thumb and metacarpophalangeal joint are reconstructed,
the range of motion should be adjusted appropriately
according to the healthy side. If you want to increase the
metatarsophalangeal range of motion, rst extend the
second metatarsophalangeal joint and then cross the
string of Kirschner wires longitudinally, x the metatarsophalangeal joint with the metacarpophalangeal joint
as an extension position, and repair the joint shape
appropriately.
17.4.6 Case Description
Case 1 The 41-year-old male patient was admitted to the
hospital for 2.5 h due to pain and bleeding of the right thumb
caused by a bench drill injury. Physical examination: He was
in good general condition, with stable vital signs. Large area
of avulsed skin defect of the right thumb, avulsed skin was
fragmentary, no replanting condition, a nail bed was present
and function was limited. After admission, routine preoperative preparation for reconstruction was given, and surgical
contraindications were excluded. The thumb was reconstructed by a Siamese ap of the right great toe pulp, bular
dorsal ap of the proximal segment and dorsal ap of the
proximal segment of the second toe transplantation under
general anesthesia in an emergency, and the donor site was
covered by a free 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 he returned to the ward safely. Routine reconstruction
treatment was given after the operation. Twenty-four months
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.17.8).
17.4 Reconstruction ofDegloving Defects ofFingers
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Fig. 17.8 Reconstruction of degloving defect of the right thumb by
Siamese ap transplantation. (a) Preoperative condition of nger
defect. (b) Preoperative design of the donor site (dorsal side). (c)
Preoperative design of the donor site (plantar side). (d) Preoperative
design of the bular ap of the great toe. (e) Dissociation of the ap. (f)
The dissociated ap. (g) Blood vessels distribution of the ap. (h) The
wound of the donor foot. (i) The dorsal view of the reconstructed thumb
after the operation. (j) The radial view of the reconstructed thumb after
the operation. (k) The palmar view of the reconstructed thumb after the
operation. (l) The donor site covered by free skin graft
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