59 Failed Digit Replant: Toe-to-Hand Transfer
59.1 Patient History Leading to the Specific Problem
A 34-year-old male patient sustained a complete amputation of the right index, long, and ring fingers by a press machine (▶Fig. 59.1).
After replantation failed, the index finger was closed primarily at the middle phalanx. The long finger was disarticulated at the distal interphalangeal (DIP) joint and soft tissue was lost distal to the proximal interphalangeal (PIP) joint. The radial pulp of the ring finger was defected. The patient was eager to recover the original length and shape of the index and long fingers. First, the open wound of the long and ring fingers was covered with distant groin flap to maintain proximal phalangeal bone for the next stage of toe transfer procedure (▶Fig. 59.2).
After division of the groin flap, secondary division between the long and ring fingers was performed (▶Fig. 59.3).
59.2 Anatomic Description of the Patient’s Current Status
The patient now has soft tissue covering the foreshortened right index and long fingers. The ring finger had a minor soft-tissue defect closed but did not require any bone shortening. There is motion at the PIP joints of each finger. The index is amputated just distal to the PIP joint, whereas the long finger is amputated at the DIP joint. The foreshortened fingers inhibit key pinch and render the fingers dysfunctional.
Fig. 59.1 Amputation of the distal aspect of the index, long, and ring fingers.
Fig. 59.2 (a, b) A groin flap was used to cover the exposed bone at the end of the long and ring fingers.
Fig. 59.3 Division and inset of the groin flap provided early coverage of the exposed bone of the long and ring fingers.
Fig. 59.4 (a–c) Cruciform incision markings on the recipient site.
59.3 Recommended Solution to the Problem
Second toe transfer is the recommended reconstruction of the index and long fingers. The toe size matches appropriately and the neurovascular pedicles are of similar sizes for each of the donor and recipients. The soft tissue on the fingers should be allowed to mature for a number of months to limit inflammation and edema. A great toe would be too large for the fingers. Lengthening procedures such as distraction osteogenesis would create longer fingers but would not restore sensation and would not be as aesthetic.
Six months later, bilateral second toe-to-hand transfer was carried out to reconstruct the index and long fingers.
59.4 Technique
For the toe transfer, dissection of the recipient site begins under upper arm tourniquet control. A cruciform incision was made on the distal end of the finger stump (▶Fig. 59.4).
Four skin flaps were developed away from the phalangeal bone and tendons were defatted. The digital nerves were isolated, trimmed sparingly down to the level of normal-looking fascicles, and tagged with 6–0 black silk sutures. The flexor digitorum profundus and the extensor digitorum communis tendons were also isolated. The distal end of the middle phalangeal bone remnant was freshened with an electric saw at the desired level. To carry out the arterial anastomosis at the proximal site where the common digital artery divides distally into two digital arteries, a longitudinal incision of about 2 cm was made at the proximal volar web space. Directly opposite this at the dorsum of the hand, another 2-cm longitudinal incision was made for the dissection of one or two subcutaneous veins. To avoid an unsightly scar made by a long incision or by a skin graft on the reconstructed fingers, a subcutaneous tunnel was created by bluntly passing a silicone drain or Nelaton catheter between two incisions of the digit and the web space. Through this tunnel, the neurovascular pedicle of the toe flap gains access to the web space of the hand.
Regarding the dissection of the donor site along the circumference of the second toe, a zigzag incision was made at the desired level (▶Fig. 59.5).
