One-stage reconstruction of four fingers in children using microsurgical autotransplantation of foot tissue complexes

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Abstract

BACKGROUND: Toe-to-hand transfer is still the most promising and relevant method for restoring fingers that are missing from birth or after injury. In cases requiring the restoration of two or more digits, simultaneous transplantation of tissue complexes from both feet, including one or two toes, is possible and necessary. Thus, a maximum of four fingers can be restored during one operation. Such operations, according to the literature, are performed extremely rarely because they are very extensive and time-consuming.

AIM: To present the results of simultaneous microsurgical autotransplantation of four toes to the hand in children with congenital and acquired pathologies.

MATERIALS AND METHODS: The study used clinical, radiological, and biomechanical methods to assess the results of nine patients with congenital and acquired upper limb deformities who underwent simultaneous microsurgical autotransplantation of two tissue complexes from each foot, including toes II–III. The indications for performing this method of microsurgical reconstruction in children with the absence of four (or all five) fingers have been determined. The results, postoperative complications, and conditions of the donor and recipient zones were analyzed.

RESULTS: To date, 914 such operations have been performed in children. In nine cases, four toes were simultaneously transplanted (two from each foot). The average age of the patients was 4.2 years. Two children had congenital malformations of the hand, and seven had consequences of trauma. In eight cases, fingers II–V were restored, and in one case, fingers I–IV were restored. Complications associated with impaired blood circulation in the grafts were observed in 22% of the cases; however, they were temporary. All transplanted grafts survived. All patients required continued surgical treatment after the toe transfer to improve their appearance and function. Biomechanical examination methods showed complete restoration of function on average of 4 months (±1 month) after surgery.

CONCLUSIONS: This study showed the possibility and effectiveness of using toes for hand transfer in children with both congenital and acquired hand pathologies that require the restoration of four fingers. Simultaneous microsurgical transplantation of toes ensures the restoration of a good appearance of the hand and its functionality.

About the authors

Sergey I. Golyana

Turner Scientific Research Institute for Children’s Orthopedics

Author for correspondence.
Email: ser.golyana@yandex.ru
ORCID iD: 0000-0003-1319-8979
SPIN-code: 8360-8078

Dr. Sci. (Med.)

Russian Federation, Saint Petersburg

References

  1. Shvedovchenko IV, Kol’tsov AA. Peresadka pal’tsev stopy na kist’ u detei s vrozhdennoi i priobretennoi patologiei — osnovnye problemy i puti ikh resheniya. Annaly plasticheskoi, rekonstruktivnoi i ehsteticheskoi khirurgii. 2017;(1):143. (In Russ.)
  2. Golyana SI, Avdeychik NV, Grankin DY, Safonov AV. Microsurgical toe-to-hand transfer in children. Modern Problems of Science and Education. Surgery. 2019;(6):150. (In Russ.) doi: 10.17513/spno.29371
  3. Jones NF, Clune JE. Thumb amputations in children: classification and reconstruction by microsurgical toe transfers. J Hand Surg Am. 2019;44(6):519.e1–519.e10. doi: 10.1016/j.jhsa.2018.08.013
  4. Avdeychik NV, Golyana SI, Grankin DY, et al. Possibilities of using microsurgical autotransplantation of tissue complexes in children. Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(4):437–450. (In Russ.) doi: 10.17816/PTORS17896
  5. Nagrath N, Duggan E, Thurley N, Rodrigues JN. A Systematic review of the outcomes of microsurgical toe transfer for metacarpal and metacarpal-like hand deformity. J Hand Surg Asian Pac. 2022;27(1):32–42. doi: 10.1142/S2424835522500199
  6. Chi Z, Song DJ, Tian L, et al. Reconstruction of combined thumb amputation at the metacarpal base level and index amputation at the metacarpal level with pollicization and bilateral double toe composite transfer. J Plast Reconstr Aesthet Surg. 2017;70(8):1009–1016. doi: 10.1016/j.bjps.2017.05.032
  7. Tikhonenko TI, Golyana SI, Sokolova NE, et al. Evaluation criteria microcirculatory complications and anticoagulant therapy in microsurgical operations. Modern Problems of Science and Education. Surgery. 2020;(6):143. (In Russ.) doi: 10.17513/spno.30328
  8. Golyana SI, Tikhonenko TI, Govorov AV, et al. Complications after toe-to-hand transfers in children with pathologies of the hand. Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2017;5(4):16–23. (In Russ.) doi: 10.17816/PTORS5416-23
  9. Minasov BSh, Garapov IZ, Biktasheva EM, et al. Results of the second toe autotransplantation for thumb reconstruction. Genij Ortopedii. 2022;28(1):34–38. (In Russ.) doi: 10.18019/1028-4427-2022-28-1-34-38
  10. Nikkhah D, Martin N, Pickford M. Paediatric toe-to-hand transfer: an assessment of outcomes from a single unit. J Hand Surg Eur. 2016;41(3):281–294. doi: 10.1177/1753193415594480.
  11. Belousov AE. Plasticheskaya rekonstruktivnaya i ehsteticheskaya khirurgiya. Saint Petersburg: Gippokrat, 1998. 744 p. (In Russ.)
  12. Buncke H Jr, Schulz WP. Experimental digital amputation and reimplantation. Plast Reconstr Surg. 1965;36(1):62–70. doi: 10.1097/00006534-196507000-00009
  13. O’Braien B. Mikrososudistaya vosstanovitel’naya khirurgiya. Transl. from eng. Moscow: Meditsina, 1981. 422 p. (In Russ.)
  14. Yoon AP, Jones NF. Long-term outcomes after toe-to-thumb transfers for burn reconstruction in children. J Burn Care Res. 2022;43(2):440–444. doi: 10.1093/jbcr/irab101.
  15. Wei FC, Al Deek NF. The battle ground between two giants: Toe transfer and hand allotransplantation. J Reconstr Microsurg. 2018;34(9):678–680. doi: 10.1055/s-0038-1639513
  16. Nakanishi A, Kawamura K, Omokawa S, et al. Quality of life in patients with toe-to-hand transplantation. J Plast Surg Hand Surg. 2018;52(6):359–362. doi: 10.1080/2000656X.2018.1520123
  17. Chen H, Jiang C, Xu Y, Sun Y. Toe-to-finger combined with free flap transfer for primary one-stage post-traumatic reconstruction of the complex fingerless hand. J Plast Reconstr Aesthet Surg. 2017;70(12):1708–1714. doi: 10.1016/j.bjps.2017.07.013
  18. Julve GG, Villén GM. The multiple monoblock toe-to-hand transfer in digital reconstruction. A report of ten cases. J Hand Surg. 2004;29(3):220–227. doi: 10.1016/j.jhsb.2003.11.003
  19. Jones NF, Graham D, Au K. Bilateral metacarpal hands: Reconstruction with 6 toe transfers. Hand (NY). 2020;15(4):465–471. doi: 10.1177/1558944718810844
  20. Al Deek NF, Lin Y-T, Wei F-C. Metacarpal-like and metacarpal hand. Hand Clin. 2016;32(4):549–554. doi: 10.1016/j.hcl.2016.06.004
  21. Wei FC, Al Deek NF, Lin YT, et al. Metacarpal-like hand: classification and treatment guidelines for microsurgical reconstruction with toe transplantation. Plast Reconstr Surg. 2018;141(1):128–135. doi: 10.1097/PRS.0000000000003940
  22. Ozols D, Zarins J, Petersons A. Novel technique for toe-to-hand transplantation: the fourth-toe as an alternative option for toe-to-hand transplantation for pediatric patients. Tech Hand Up Extrem Surg. 2019;23(2):74–80. doi: 10.1097/BTH.0000000000000234

Supplementary files

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2. Fig. 1. Photo (a, b) and X-ray (c) images of the child’s right hand during hospitalization at the Turner Scientific Research Institute for Children’s Orthopedics (before the start of surgical treatment) (RUS)

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3. Fig. 2. Appearance immediately after transplanting the toes from both feet into the position of fingers II–V of the right hand (RUS)

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4. Fig. 3. Photo of the hands after the completion of multistage surgical treatment (RUS)

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5. Fig. 4. Functional result of the hand after the restoration of four fingers: a — ability to bend the restored fingers into a fist; b, c — gripping capabilities of the right hand (RUS)

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6. Fig. 5. Patient’s manual skills (RUS)

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7. Fig. 6. One of the girls’ hobbies is modeling figures from plasticine (RUS)

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8. Fig. 7. Child playing sports

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9. Fig. 8. Condition of the right hand of a 3-year-old child with a complication of injury: a — view of the hand from the dorsal surface; b — view from the palmar surface; c — schematic of the hand before surgery (RUS)

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10. Fig. 9. Marking of incisions on the hand during surgical treatment: a — view of the marking from the dorsal surface; b — view from the palmar surface (RUS)

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11. Fig. 10. Stages of mobilization of toe II–III block autograft of the left foot with simultaneous separation of toes II and III on a common vascular pedicle: a — appearance of the feet before surgery; b — isolated (vascular) pedicle of toe II–III block autograft; c — toes II and III of the left foot after their separation (RUS)

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12. Fig. 11. Schemes of the step-by-step separation of toes II and III of the left foot into two autografts with a common vascular pedicle: a — scheme of the incisions on the foot; b — scheme of the incisions between toes II–III of the autograft block; c, scheme of the arterial source of autograft block (1 — dorsal artery of the foot; 2 — dorsal metatarsal artery; 3 — first plantar metatarsal artery; 4, second plantar metatarsal artery; 5 — third plantar metatarsal artery; 6 — fragment of the plantar arterial arch); d — scheme of the stage of the second plantar metatarsal artery branch intersection, namely, digital artery of finger II (7 — place of intersection); e — scheme of the separation of the autograft-block’s toes (1 — dorsal artery of the foot; 2 — dorsal metatarsal artery; 3 — first plantar metatarsal artery; 4, second plantar metatarsal artery; 5 — third plantar metatarsal artery; 6 — fragment plantar arterial arch; 8 — site of ligation (coagulation) of the digital artery of toe II); f — scheme of the venous source of the autograft block of toes II–III (9 — great saphenous vein of the foot; 10 — branches of the great saphenous vein to the toes of the autograft block); g — scheme of the separation of the autograft block’s veins (11 — site of ligation of the venous branches between toes II–III) (RUS)

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13. Fig. 12. Appearance of the hand immediately after the restoration of fingers I–IV of the right hand in a 3-year-old child, with complications of injury, using autotransplantation of two finger II–III autograft blocks of both feet with simultaneous separation of the toes in one autograft: a — view from the hand dorsum; b — view from palmar surface of the hand; c — view from the radial surface of the hand; d, scheme of the autograft location on the hand; e — scheme of the location and anastomosis of the autograft’s arteries (1 — dorsal foot artery; 2 — dorsal metatarsal artery; 3 — first plantar metatarsal artery; 4 — second plantar metatarsal artery; 5 — third plantar metatarsal artery; 6 — fragment of the plantar arterial arch; 12 — proximal fragment of the dissected radial artery; 13 — distal fragment of the dissected radial artery) (RUS)

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14. Fig. 13. Plantogram of the feet of a 4-year-old patient: 1 year after the operation of bilateral taking of toe II–III block. (Despite noticeable changes in the imprint’s anatomical shape of the operated feet, no difference was found in the width of their anterior parts. Foot function was not impaired, and the load distribution on both feet was even) (RUS)

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15. Fig. 14. Computer statokinesiogram of the patient after toe-to-hand transfer from the right foot. Reducing the eccentricity of the center-of-pressure (CoP) deviation from an ellipse with open eyes to a circle with closed eyes. Left: projection of the child’s real CoP relative to the average normative position of the CoP; right, graphical representation of the real statokinessiogram

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