Journal of Plastic, Reconstructive & Aesthetic Surgery (2013) 66, 973e977

A technique for the non-microsurgical reconstruction of thumb tip amputations

Dong Han a,b, Hongbin Sun b,*, Yunbo Jin a, Jiao Wei a, Qingfeng Li a
Department of Plastic and Reconstructive Surgery, Ninth Peoples Hospital, Medical School of Shanghai Jiao Tong University, Shanghai, China b Department of Hand Surgery, The China Japan Union Hospital, Jilin University, Changchun, China Received 12 September 2012; accepted 9 March 2013
a

KEYWORDS
Thumb tip amputation; Nailbed; Periosteal ap; Reconstructive surgical procedures

Summary Purpose: This article aims to present a technique for thumb tip amputations using a homodigital soft-tissue/periosteum ap and a portion of the amputated digit. Methods: Eight patients (aged 21e53 years) with avulsion thumb tip amputations were reviewed. We report a new technique in which a bone and nailbed composite graft was taken from the amputated portion of the thumb and a dorsoulnar ap combined with periosteum was harvested from the rst metacarpal and designed to cover the volar bone. Patients were evaluated 6 months after surgery for functional and cosmetic outcomes. Results: The radiographic evaluation showed bone healing in all of the patients 5 weeks postoperatively. With regard to pulp reconstruction, there was good recovery of static two-point discrimination. For both the reconstructed area and the donor site, the nal results were good in terms of reliability and coverage as well as from a cosmetic perspective. Conclusions: This technique was found to be safe and effective. It is a good option for the non-microsurgical reconstruction of crushed and avulsed amputations of the distal thumb. Crown Copyright 2013 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. All rights reserved.

Avulsions and amputations of the thumb tips are common injuries to the upper extremity, and they require precise

* Corresponding author. Department of Hand Surgery, China Japan Union Hospital, Jilin University, No. 126, Xiantai Road, Changchun 130031, China. Tel.: 86 (0) 431 84995222; fax: 86 (0) 431 84641026. E-mail address: sunhongbin12000@163.com (H. Sun). 1748-6815/$ - see front matter Crown Copyright 2013 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.03.013

wound care for optimal results. Microsurgical replantation of an amputated thumb tip is one way to achieve a painless nger with good sensitivity and mobility.1 For extensive crushing and avulsed amputations of the thumb, which preclude replantation, there are numerous reconstruction modalities: primary closure, skin grafting and close and distant aps.2,3 The indications, advantages and disadvantages of various reconstructive procedures for

974 distal nger injuries have been described by Scheker et al.4 The main aim of the treatment of thumb tip amputations with no indication of replantation is to establish an acceptable functional and cosmetic outcome. It is more acceptable to use the bone and nail gathered from the amputated part as a graft to preserve cosmesis and function.5e8 However, the graft bone is considered dead bone and can only heal through revascularisation. The critical point in the utilisation of the bone and nail tissue as a graft for reconstruction is to choose a ap that provides vascularity and periosteum to stimulate bone healing. We have used periostealecutaneous composite aps to cover bone and nailbed composite grafts taken from the amputations to restore thumb function and appearance with acceptable results.

D. Han et al.

Materials and methods

Between 2007 and 2011, thumb tip amputations were treated by our technique in eight patients. The mean age of the patients was 35 (range, 21e53) years. Replantation was not indicated in any of these patients. Six patients had crush injuries with amputations and two patients had avulsion-type amputations. The level of thumb tip amputations was proximal to the germinal matrix and distal to the interphalangeal joint. Patients were followed up for a mean of 8 months (range 6e12).

Figure 1 a. A case of crush amputation of the thumb tip. The amputation level was at the proximal to the germinal matrix of the nailbed (dorsal view). b. The bone and nailbed composite graft from the amputated part.

Surgical technique
Patients had surgery under a brachial plexus block using tourniquet control and loupe magnication. According to the surgical technique described by Alagoz et al.,7 the palmar segment, including the periosteum of the amputated part, was excised except for the bone and the attached germinal and sterile matrix of the nailbed; this composite graft was xed to the stump with a single k-wire (Figure 1). The proximal digital nerve stumps were isolated, carefully pulled distally and cleanly divided with an operating scalpel so that the cut end retracted well proximal to the level of the bone resection. The pivot point at the level of the neck of the proximal phalanx (2.5 cm proximal to the cuticle) is marked on the skin. The axis of the ap is traced over the dorsoulnar aspect of the rst metacarpal and proximal phalanx (1 cm from the median axis at the level of the neck of the proximal phalanx).9,10 A reverse homodigital dorsal ulnar ap with periosteum from the rst metacarpal was created according to the dimensions of the defect. Skin was incised at the periphery, and the ap was raised in a proximal-to-distal direction. While raising the ap, the extensor pollicis brevis and extensor pollicis longus muscle tendons were located, and the periosteum was dissected proximally from the rst metacarpal carefully. To preserve the vessel branches between the subcutaneous tissue and the periosteum, a few stitches were used to hold the periosteum and the subcutaneous tissue together to prevent them from peeling off the ap and to ensure sufcient blood supply to the periosteum. The pedicle was elevated with a strip of skin and subdermal dissection along the dorsoulnar axis of the thumb towards the pivot point. The incision to the skin must be made supercial to preserve the pedicle. The pedicle was preserved at 1 cm in width to ensure the connections with the digital artery and to prevent postoperative venous insufciency.9,10 Proximal-to-distal dissection of the pedicle must end near the pivot point to protect the anastomosis with the palmar vessels. The skin between the defect and the pivot point should be incised and elevated so that the ap can be transposed and sutured covering the defect (Figure 2). Tunnelling of the ap is not recommended because of the risk of venous congestion. The tourniquet is released with the ap in its original position to ensure both adequate rell of the vascular pedicle and vascular ow to the ap. The ap is rotated and sutured in place with a few stitches. During this process, it is important that the periosteum is attened and covers the fracture site when periosteum sutures are placed. The ap and pedicle must not be under any tension. It is better to leave the wound partially open or to place a small skin graft over the exposed pedicle. The donor site can be closed directly or the exposed bone can be covered by the adjacent fasci and a skin graft, depending on the dimensions of the ap and the skins elasticity. (In this case, the skin graft was obtained from the amputated thumb tip.) (Figure 3). Thumb is immobilised for 5 weeks, and then, according to the radiographs, the k-wire is taken out and protected active mobilisation of the thumb encouraged. In addition to the viability of the ap, sensation and bone healing, factors observed included nail cosmesis and function.

Non-microsurgical reconstruction of thumb tip

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Figure 2 a. Ulnar dorsal digital artery and its anastomosis with the ulnar palmar digital artery at the neck of the rst phalanx. Distance between the median axis of the thumb and ulnar dorsal digital artery, 1 cm at the level of the rst phalanx. (A, ulnar dorsal digital artery). Distance between the palmar anastomosis and the cuticle of the nail, 2.3 cm. b. A dorsal ulnar ap with periosteum from the rst metacarpus in the snuffbox was designed and dissected. (+ The rst metacarpus; * Periosteum from the rst metacarpus).

Results
The clinical data are summarised in Table 1. The ap sizes ranged from 1.5 1.5 to 2.5 2 cm. At a minimum follow-up of 6 months (mean 8, range 6e10), the bone and nailbed composite grafts had survived with no obvious complications in all thumbs. The radiographs indicated bony union at 5 weeks postoperatively in all cases (Figure 4). There were no problems with the healing of the nailbed, and at the 6 months follow-up, the nails were acceptably cosmetic, but the nail plate was hypertrophic, especially in the distal portion (Figure 5). The sensitivity of the thumb was measured and was compared to the opposite thumb (the two-point discrimination values over the ap were between 8 and 11 mm, mean 9.9 mm) at 6 months postoperatively (Table 1). No patient complained about the resulting scar, painful neuroma or persistent cold intolerance.
Figure 3 The ap was covered on the bone and nailbed composite graft and the nail was replaced after drilling. The donor site was covered by the adjacent fasci and a skin graft. (Dorsal view).

ap was used to cover the bone and nailbed and composite grafts taken from the amputated part were used to restore the thumb tip function and cosmesis.7 The bone from the amputation was essentially dead bone and revascularisation was the only way for healing to occur; but it took so long that the possibility of bone necrosis and nonunion was a problem. Vascularised periosteum is an elastic and exible membrane with known osteogenic properties and is suitable for skeletal reconstruction because it is readily available and adaptable to the shape of the recipient area.11 The reverse homodigital dorsal ap of the thumb is
Table 1 Case No. Type of injury and outcome. Sex Type of injury Two-point discrimination values, mm 11 10 9 11 11 10 9 8

Discussion
Avulsion of the thumb tip usually causes serious cosmetic and functional problems. The treatment of thumb tip amputations should include not only good functional but also acceptable cosmetic results with the preservation of nger length. For thumb tip amputation distal to the germinal matrix of the nailbed, a subcutaneous pulp ap combined with the cap technique of the nail complex for avulsed thumb tip is a suitable method.6 However, for thumb tip amputations proximal to the nail root, this technique could be inapplicable as a result of nail regeneration problems. Alagoz described one method in which a homodigital artery

1 2 3 4 5 6 7 8

Male Male Female Male Male Female Male Male

Crush amputation Crush amputation Crush amputation Crush amputation Avulsion amputation Crush amputation Crush amputation Avulsion amputation

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D. Han et al.

Figure 5 The cosmetic appearance of the nail and donor-site were acceptable at 6 months after surgery (dorsal view). Figure 4 A radiographic evaluation clearly indicated that the bone trabeculae had crossed the junction of the bone extremities in the postoperative 5 weeks.

a good option for the reconstruction of the thumb because of its rich vascular supply, low morbidity and preservation of the primary artery.9,10 Based on these operative techniques, we developed a new procedure, termed reverse dorsoulnar ap with periosteum, in which we used a dorsoulnar ap and vascularised periosteum to re-establish the function and cosmesis of the thumb ray. This ap with periosteum not only covered and nourished the bone and nailbed composite grafts but also provided excellent osteogenic properties and promoted bone healing. Faster healing allowed for early motion and less potential for stiffness. According to the radiographic evaluation at 5 weeks postoperatively, the dissection of the vascularised periosteum from the metacarpus did not damage the bone tissue. However, the use of periosteal aps is not recommended in skeletally immature patients to avoid potential consequences on skeletal growth. In our experience, the thumb was typically immobilised for 5 weeks, and if the radiographs demonstrated union, the k-wire was removed and protective active mobilisation was encouraged. The outcome was satisfactory in all patients. Full exion and extension of the thumb were maintained, and a good recovery of static two-point discrimination was obtained. However, the follow-up at 6 months demonstrated that the ap had retracted and the bone/terminal tuft had undergone a little resorption on radiographs. The length of the thumb was acceptable, and

patients were satised with the thumbs function and appearance. We advocate the preservation of a sufcient amount of soft tissue around the vascular pedicle to overcome the venous insufciency while preserving the narrow cutaneous bridge in the ap. This ap design with a strip of skin takes advantage of the subdermal plexus and avoids compression and vascular compromise from pressure. Because the dorsal skin of the hand is stretchable and the excision of a narrow cutaneous bridge does not obviously increase the tension of the skin, any hypertrophic scarring or contracture resulting from the additional skin resection did not occur in our patients. The nail plate, especially the distal part, was hypertrophic due to malnutrition as a result of poor vascular supply in the early healing phase. A split nailbed graft from another digit or toe, such as the big toe, can be done to improve the cosmetic appearance of the nail, especially in women and adolescents. With respect to the cosmesis, we nd poor results with the hair-bearing skin of the dorsal hand on the thumb tip rather than the use of the homodigital ap using non-hair bearing more palmar-like skin. For patients with thick hair, especially females, electrolysis and laser therapy might be a complementary procedure for this technique. Nevertheless, a problem that remains unresolved is the sensory resurfacing in the palmar reconstruction of the thumb. Brunelli9 and Tera n12 et al. reported that no important difference was observed between the patients in whom the nerve of the ap had been reconnected to one of the volar collateral nerves of the thumb and those who had not undergone nerve reconnection. Sensory recovery seems to depend on the age of the patient and the quality of the

Non-microsurgical reconstruction of thumb tip substratum of the donor site.12 In our cases, static two-point discrimination was evaluated only for palmar reconstruction, and we found a mean value of 9.9 mm with no nerve repair. Further cases are needed to evaluate the possibility of restoring sensation by nerve reconnection techniques. The drawbacks of the reverse homodigital dorsal ap with periosteum were the extended operation time when compared with local aps, the necessity of microsurgical instrumentation and the meticulous dissection of the pedicle and periosteum. In addition, total or partial ap failure is a possibility.

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References
1. Dubert T, Houimli S, Valenti P, Dinh A. Very distal nger amputations: replantation or reposition-ap repair? J Hand Surg 1997;22 B:353e8. 2. Shibu MM, Tarabe MA, Graham K, Dickson MG, Mahaffey PJ. Fingertip reconstruction with a dorsal island homodigital ap. Br J Plast Surg 1997;50:121e4. 3. Han D, Hu HT, Jiang H. The subcutaneous pulp ap for ngertip defects. J Hand Surg 2008;33A:254e6. 4. Scheker LR, Becker GW. Distal nger replantation. J Hand Surg 2011;36A:521e8. 5. Uysal A, Kankaya Y, Ulusoy MG, et al. An alternative technique for microsurgically unreplantable ngertip amputations. Ann Plast Surg 2006;57:545e51. 6. Han D, Li QF. New technique for non-microsurgical reattachment of avulsed ngertips in adults. J Plast Surg Hand Surg 2010;44:204e8. 7. Alagoz MS, Uysal CA, Kerem M, Sensoz O. Reverse homodigital artery ap coverage for bone and nailbed grafts in ngertip amputations. Ann Plast Surg 2006;56:279e83. 8. Braga-Silva J, Jaeger M. Repositioning and ap placement in ngertip injuries. Ann Plast Surg 2001;47:60e3. 9. Brunelli F, Vigasio A, Valenti P, Brunelli GR. Arterial anatomy and clinical application of the dorsoulnar ap of the thumb. J Hand Surg 1999;24A:803e11. 10. Pelissier P, Pistre V, Casoli V, Lim A, Martin D, Baudet J. Dorsoulnar osteocutaneous reverse ow ap of the thumb. J Hand Surg Br 2001 Jun;26(3):207e11. 11. Chen AC, Lin SS, Chan YS, Lee MS, Ueng SW. Osteogenesis of prefabricated vascularized periosteal graft in rabbits. J Trauma 2009;67:165e7. 12. Tera n P, Carnero S, Miranda R, Trillo E, Estefan a M. Renements in dorsoulnar ap of the thumb: 15 cases. J Hand Surg Am 2010 Aug;35(8):1356e9.

Conclusion
The homodigital soft-tissue/periosteum ap and bone and nailbed composite grafts are safe, effective and relatively easy. It is a good option for the non-microsurgical reconstruction of crushing, avulsing amputations of the distal thumb.

Conict of interest statement

None.

Ethics
The study was performed according to the local ethical guidelines.

Funding source
The conduct of this study was not funded.