Graham D. Lister

Reconstruction of the hand with free microneurovascular toe-to-hand transfer: experience with 54 toe transfers.

Over a period of 6 years, 54 toe-to-hand transfers were performed, 24 for thumb and 30 for finger reconstruction. Refinements in evaluation, preparation, and surgical technique are detailed. Forty-nine toes (90.7 percent) survived. Exploration was required for circulatory compromise following 13 transfers (34.2 percent), to good effect in 9 (69.2 percent). Secondary surgery was performed in 26 cases, consisting of tendolysis, osteotomy, and deepening of the first web space. Review was undertaken at an average of 1 year and 9 months after transfer. Power grip averaged 28.5 percent of the normal hand and pinch strength 26.6 percent, great toe transfer giving 35.7 percent and second toe transfer to thumb giving 15.6 percent strength compared with normal. Static two-point discrimination of less than 10 mm was present in 37.5 percent of those studied under 2 years after surgery and in 75 percent of those studied more than 2 years later. The choice of procedure for thumb reconstruction is discussed in detail, as are supplementary skin cover, vascular considerations, and the high exploration rate.

Microsurgical transfer of the second toe for congenital deficiency of the thumb.

Twelve second-toe transfers have been performed to substitute for thumbs congenitally deficient through constriction ring syndrome, symbrachydactyly, and true transverse arrest. The children were on average 3 years of age, and the youngest was undertaken at 10 months. Anatomic variations were the rule in the six cases of transverse absence and the three cases of symbrachydactyly, requiring nerves, tendons, and vessels in the toe be connected to whatever appropriate structure could be located. All transfers survived, and only one required exploration. Sensation appeared good in the 11 seen in later review, but interphalangeal motion was achieved in only 3. However, good use was made of the digit by all except one patient, an early patient in whom there was not an adequate skeleton on which to base the transfer. This small series suggests that in appropriate cases toe transfer can be undertaken early for congenital deficiency with little fear of encountering microsurgical problems unique to the infant.

Preferential Use of the Posterior Approach to Blood Vessels of the Lower Leg in Microvascular Surgery

A posterior approach to the vessels of the lower leg, with particular emphasis on the posterior tibial artery, is presented as the method of choice for microvascular free-tissue transfer to the region. This approach offers wide exposure, better definition of the zone of injury, appropriate selection of the recipient vessel and of the site of anastomosis, and enough room for microsurgical work. Exposing the large posterior tibial artery down to the distal third of the lower leg facilitates the use of end-to-side anastomosis and makes the transfer of large muscle flaps to that region more predictable, in part by obviating the need for long vein grafts. This exposure leaves no functional and few aesthetic deficits.

Use Of An Innervated Skin Graft To Provide Sensation To The Reconstructed Heel

An innervated skin graft--a full-thickness skin graft with its nerve supply intact--is presented. In the case described, the sural nerve was preserved and an island of skin supplied by it was transposed to provide sensation to a heel pad, which had first been reconstructed by a cross-thigh flap. This transposed sensation has allowed full activity for 3 years in a young boy wearing normal footwear. This suggests that ulceration of all, or most, heel reconstructions is due to lack of sensation and, further, that the necessary sensation can be provided by this technically simple transposition of an innervated skin graft.

Arterial T and Y grafts

Presented is the use of an autogenous arterial T graft for the salvage of a thrombosed arterial end-to-side anastomosis. The T-graft concept also offers the possibility of replacing a segment of artery in patients with arterial vessel wall defects, stenosis, obliteration, or disease during free latissimus dorsi or scapular flap transfer. The arterial T graft is harvested from the axilla and consists of segments of the subscapular, circumflex scapular, and thoracodorsal arteries. The large diameter of these vessels offers a good match with the arteries of the lower leg and forearm. The arterial Y graft consists of the same arteries and is used as an interpositional graft to revascularize two distal vessels from one proximal vessel.

The posterior interosseous arterial graft

The posterior interosseous artery is a suitable donor vessel for harvesting autogenous arterial grafts which are often necessary for thumb or finger revascularization or replantation. Grafts 8 to 10 cm long can be taken from the dorsal ulnar aspect of the forearm ranging in caliber from 1 to 1.5 mm. The arterial graft can be harvested together with the lateral branch of the posterior interosseous nerve, offering the possibility of vascularized nerve transfer. Removal of the posterior interosseous artery does not influence peripheral perfusion or leave functional deficits. During dissection, care must be taken not to harm motor branches of the posterior interosseous nerve. We report a patient in whom this technique was used successfully.

The pronator quadratus muscle flap : coverage of the osteotomized radius following elevation of the radial forearm flap

Skin-graft take following elevation of the osteocutaneous radial forearm flap has been shown to be difficult. The pronator quadratus muscle flap can be elevated to cover the exposed osteotomized radius and flexor carpi radialis and brachioradialis tendons. This technique is technically easy to perform and may significantly reduce donor-site wound-healing problems.

Adjustable dynamic external splint for control of first web contracture.

A method is presented to overcome problems of first web space contracture by means of a dynamic, continuously adjustable, wedge-shaped splint. The device is easily constructed of inexpensive material by physician or hand therapist. The splint is custom-tailored to the individual patient and is lightweight and comfortable, promoting good patient compliance. Its continuously adjustable nature maximizes its effects throughout therapy, and the even distribution of the pressure makes for a high surface area of patient/splint contact for even pressure distribution and eliminates the problems of skin necrosis, even with lengthy applications.