Transverse Distraction of Great Toe to Enlarge the Donor Site before Finger Reconstruction

Abstract

Partial great toe transfer is widely used in finger reconstruction. Although satisfactory results have been reported at the recipient’s hand, the donor foot still presents with many problems due to the large amount of tissues harvested. In this study, the Ilizarov technique was utilized to enlarge the great toe in order to minimize the amount of tissue sacrificed of the donor foot. In this retrospective study, 23 patients (30 toes) underwent transverse distraction of the great toe for finger reconstruction from September 2020 to December 2022. The width of the contralateral normal finger was set as the objective width gained of distraction. At the last follow-up, the changes of bone, toenail, plantar skin, vessel, and nerve of the great toe were measured, and postoperative complications were assessed. The time for active distraction was 46.1 ± 8.3 days, with a widening rate of 0.41 ± 0.08 mm/day. Counting in the time for latency and consolidation, the time of treatment with external fixation was 84 ± 11.9 days. At the last follow-up, the average width of the distal phalanx of the great toe increased from 13.1 to 28.1 mm (p < 0.001). The width of the toenail increased from 15.8 to 30.3 mm (p < 0.001), and the width of the plantar pulp increased from 25.6 to 38.8 mm (p < 0.001). Computed tomography angiography (CTA) and Doppler ultrasound confirmed that the digital arteries and nerves of the great toe were intact after distraction surgery. Two patients needed revision surgery due to complications of pin loosening or premature consolidation. With the help of the Ilizarov technique, the great toe is effectively enlarged after transverse distraction. Multiple tissues of the great toe, including bone, nail, and plantar skin, are regenerated, and more tissues were preserved after toe-to-hand transfer. To the best of our knowledge, this is a novel method to enlarge the donor site for finger reconstruction.

Keywords

Donor-site Morbidity / Distraction Osteogenesis / Ilizarov Technique / Partial Great Toe Flap / Toe-to-hand Transfer

References

[1] Hirasé Y, Kojima T, Matsui M. Aesthetic fingertip reconstruction with a free vascularized nail graft: a review of 60 flaps involving partial toe transfers. Plast Reconstr Surg. 1997; 99(3): 774–784.

[2] Wang ZT, Sun WH. Cosmetic reconstruction of the digits in the hand by composite tissue grafting. Clin Plast Surg. 2014; 41(3): 407–427.

[3] Wang Z, Sun W, Lineaweaver WC, Hao L, Qiu S, Zhang L, et al. Distal finger reconstruction by bilateral lateral hallux osteo-onychocutaneous free flap. Ann Plast Surg. 2019; 82(3 Suppl 2): S157–S161.

[4] Koshima I, Inagawa K, Urushibara K, Okumoto K, Moriguchi T. Fingertip reconstructions using partial-toe transfers. Plast Reconstr Surg. 2000; 105(5): 1666–1674.

[5] Tsai TY, Fries CA, Hsiao JC, Hsu CC, Lin YT, Chen SH, et al. Patient-reported outcome measures for toe-to-hand transfer: a prospective longitudinal study. Plast Reconstr Surg. 2019; 143(4): 1122–1132.

[6] Pan YW, Zhang L, Tian W, Tian G, Zhao J, Guo X. Donor foot morbidity following modified wraparound flap for thumb reconstruction: a follow-up of 69 cases. J Hand Surg Am. 2011; 36(3): 493–501.

[7] Sosin M, Lin CH, Steinberg J, Hammond ER, Poysophon P, Iorio ML, et al. Functional donor site morbidity after vascularized toe transfer procedures: a review of the literature and biomechanical consideration for surgical site selection. Ann Plast Surg. 2016; 76(6): 735–742.

[8] Foucher G, Binhammer P. Plea to save the great toe in total thumb reconstruction. Microsurgery. 1995; 16(6): 373–376.

[9] Nakanishi A, Kawamura K, Omokawa S, Shimizu T, Iida A, Tanaka Y. Quality of life in patients with toe-to-hand transplantation. J Plast Surg Hand Surg. 2018; 52(6): 359–362.

[10] Yamada N, Kurokawa M, Kakibuchi M, Yano K, Hoskawa K. A new idea to avoid complications at the donor site of the wrap-around flap with a tissue expander. Plast Reconstr Surg. 2003; 112(6): 1744–1745.

[11] Zhu YL, Guo BF, Zang JC, Pan Q, Zhang DW, Peng Y, et al. Ilizarov technology in China: a historic review of thirty-one years. Int Orthop. 2022; 46(3): 661–668.

[12] Kempton SJ, McCarthy JE, Afifi AM. A systematic review of distraction osteogenesis in hand surgery: what are the benefits, complication rates, and duration of treatment? Plast Reconstr Surg. 2014; 133(5): 1120–1130.

[13] Gubin AV, Borzunov DY, Marchenkova LO, Malkova TA, Smirnova IL. Contribution of G.A. Ilizarov to bone reconstruction: historical achievements and state of the art. Strategies Trauma Limb Reconstr. 2016; 11(3): 145–152.

[14] Lam WL, Wei FC. Toe-to-hand transplantation. Clin Plast Surg. 2011; 38(4): 551–559.

[15] Waljee JF, Chung KC. Toe-to-hand transfer: evolving indications and relevant outcomes. J Hand Surg Am. 2013; 38(7): 1431–1434.

[16] Kanchanathepsak T, Gotani H, Hamada Y, Tanaka Y, Sasaki K, Yagi H, et al. The effectiveness of distraction lengthening in traumatic hand amputation with Ilizarov mini fixator. Injury. 2020; 51(12): 2966–2969.

[17] Del Piñal F, Moraleda E, de Piero GH, Ruas JS, Galindo C. Onycho-osteo-cutaneous defects of the thumb reconstructed by partial hallux transfer. J Hand Surg Am. 2014; 39(1): 29–36.

[18] Shen XF, Mi JY, Xue MY, Zhao G, Qiang L, Zhou X, et al. Modified great toe wraparound flap with preservation of plantar triangular flap for reconstruction of degloving injuries of the thumb and fingers: long-term follow-up. Plast Reconstr Surg. 2016; 138(1): 155–163.

[19] Chen Y, Ding X, Zhu Y, Jia Z, Qi Y, Chen M, et al. Effect of tibial cortex transverse transport in patients with recalcitrant diabetic foot ulcers: a prospective multicenter cohort study. J Orthop Transl. 2022; 36: 194–204.

[20] Liu Z, Xu C, Yu YK, Tu DP, Peng Y, Zhang B. Twenty years development of tibial cortex transverse transport surgery in Pr China. Orthopa Surg. 2022; 14(6): 1034–1048.

RIGHTS & PERMISSIONS

2024 The Author(s). Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.