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TEXT BOOK READING

THUMB RECONSTRUCTION

Dr. Thanial Jimmy Andre

Pembimbing
D r . B e t a S u b a k t i N , S P. B P - R E ( K )

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“Loss of thumb function impairs the entire upper limb, and
carries a high priority for reconstruction”

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Grabb and Smith's Plastic Surgery, Seventh Edition by Charles H. Thorne, 2014
Strong contraindications

• vascular disease
• short life expectancy, chronic pain with disuse of the limb
• unreconstructable sensory loss
• Unrealistic patient expectations
• other contraindications dictated by the common sense of the
surgeon.

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Grabb and Smith's Plastic Surgery, Seventh Edition by Charles H. Thorne, 2014
EVALUATION

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AS WITH ANY DIGITAL INJURY, INITIAL
EVALUATION INCLUDES AN ASSESSMENT OF

Soft tissue defect


Condition
Bone loss
of joints
Zone of
Neurologic
Nail bed tendon
status
injuries
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Grabb and Smith's Plastic Surgery, Seventh Edition by Charles H. Thorne, 2014
The following points relevant to thumb
reconstruction are considered:

1. What is the status of the basal joint?


2. Is there a first web space contracture or skin deficit?
3. Are there problems with the remaining digits?
4. Has the patient developed maladaptive patterns of use?
5. Do the patient’s complaints match the apparent deficit?
6. What are the patient’s expectations?

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1. What is the status of the basal joint?

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Grabb and Smith's Plastic Surgery, Seventh Edition by Charles H. Thorne, 2014
2. Is there a first web space contracture or skin deficit?

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Grabb and Smith's Plastic Surgery, Seventh Edition by Charles H. Thorne, 2014
3. Are there problems with the remaining digits?

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Grabb and Smith's Plastic Surgery, Seventh Edition by Charles H. Thorne, 2014
TYPES OF DEFICIENCIES

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Grabb and Smith's Plastic Surgery, Seventh Edition by Charles H. Thorne, 2014
Reconstruction may be either
• emergency
• urgent
• subacute
• elective

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As with any extremity injury,
reconstructive priorities are

• First HEALING
(blood supply, stable skeleton, mobile soft-tissue cover)
• and then FUNCTION
(nerve function, passive range of motion, active range of
motion).

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COMPONENT LOSSES

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• Skeletal injuries are managed by anatomic reduction and fixation.

• Nonreconstructible injuries of the interphalangeal or


metacarpophalangeal joints are treated with arthrodesis

• Carpometacarpal injuries are best salvaged with soft-tissue arthroplasty

• Composite loss of soft tissue and skeletal  urgent soft-tissue


cover  skeletal stabilization and possible bone grafting.

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Grabb and Smith's Plastic Surgery, Seventh Edition by Charles H. Thorne, 2014
“Reconstructing component loss requires
an appropriate flap.”

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Grabb and Smith's Plastic Surgery, Seventh Edition by Charles H. Thorne, 2014
Innervated flaps

Moberg palmar advancement flap


The Holevich first dorsal metacarpal flap from the index finger,
Heterodigital neurovascular sensory “island” flaps,
Free finger or toe pulp flaps
Standard local digital flaps
• V-Y advancements
• dorsal transposition
• dorsal or volar cross-finger flaps.

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Noninnervated regional flaps
 Posterior interosseous
 Radial forearm
 Intrinsic muscle flaps

”Appropriate for complex proximal


and web space defects”

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Grabb and Smith's Plastic Surgery, Seventh Edition by Charles H. Thorne, 2014
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Grabb and Smith's Plastic Surgery, Seventh Edition by Charles H. Thorne, 2014
A M P U TAT I O N

“Whenever possible, replantation should be considered for thumb amputation”

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Amputation Distal to the Metacarpophalangeal Joint

• If there is a functional remnant of the proximal phalanx, primary reconstructive


goals are length, stability, and adequate web space.
• Choices include
• bone graft with a local flap,
• osteoplastic reconstruction,
• phalangization,
• distraction lengthening,
• pedicled transfer of a damaged finger remnant to the thumb,
• or toe-to-thumb transfer.

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Amputation Proximal to the Metacarpophalangeal Joint

• When the level of amputation is at or proximal to the metacarpophalangeal joint,


the thumb ray does not project beyond the web space skin.

• Options when loss is through the distal metacarpal include


• osteoplastic reconstruction,
• pedicled finger remnant transfer,
• pollicization, and free toe transfer.

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Grabb and Smith's Plastic Surgery, Seventh Edition by Charles H. Thorne, 2014
ESTABLISHED THUMB RECONSTRUCTION
PROCEDURES

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OSTEOPLASTIC THUMB RECONSTRUCTION

Best Indication/Unique Advantages


• Partial or distal subtotal amputation
• No digit is sacrificed

Disadvantages and Special Requirements


• Multiple staged procedures may be required.
• Results may be unaesthetic: can be bulky, floppy, and without a thumb nail.
• Additional neurovascular flap is required for sensibility.

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TECHNIQUE

 Osteoplastic reconstruction involves the combination of a bone graft and flap to


lengthen the thumb remnant

 It typically involves three procedures :

• Lengthening the skeleton with an iliac crest


1 bone graft covered in a tubed distant flap

2 • Flap pedicle division

• Transfer of a neurovascular sensory island flap from the ulnar


3 side of the middle finger to the thumb’s pinch contact surface.

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TECHNIQUE

 Additional debulking flap revisions

 Donor-site variations

 A variety of free tissue transfers  including the excellent “wraparound” toe transfer

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TECHNIQUE

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PHALANGIZATION

Best Indication/Unique Advantages


• Thumb lengthening by finger transfer is a possible consideration (rare) if the thumb is
nearly long enough, such as base of proximal phalanx.
• Usually this is a single-stage operation.

Disadvantages and Special Requirements


• Phalangization may not provide much functional improvement, and may result in a very
unnatural appearance, particularly if the web is converted to a cleft by an aggressive Z-
plasty.

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TECHNIQUE

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Grabb and Smith's Plastic Surgery, Seventh Edition by Charles H. Thorne, 2014
METACARPAL DISTRACTION LENGTHENING

Best Indication/Unique Advantages


• Distal subtotal amputation (region of metacarpophalangeal [MCP] joint) is an indication for
this procedure and there is little or no donor defect except scar.

Disadvantages and Special Requirements


• Only limited lengthening is possible, and absolute cooperation is required.

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TECHNIQUE

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Grabb and Smith's Plastic Surgery, Seventh Edition by Charles H. Thorne, 2014
ON-TOP PLASTY

Best Indication/Unique Advantages


• Amputation in the area of the MCP joint is an indication for this procedure, which will
enhance the value of a damaged finger.

Disadvantages and Special Requirements


• The appropriate finger is infrequently available, and this procedure narrows the palm.
• Transferred injured parts carry a higher risk of a complication.

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TECHNIQUE

 Neurovascular pedicle transfer of the distal segment of a


damaged or partially amputated finger to lengthen the thumb

 Ray resection

 Preoperative arteriography

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Grabb and Smith's Plastic Surgery, Seventh Edition by Charles H. Thorne, 2014
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Grabb and Smith's Plastic Surgery, Seventh Edition by Charles H. Thorne, 2014
POLLICIZATION

Best Indication/Unique Advantages


• The best indication is proximal subtotal or total amputation.
• This procedure is the only satisfactory means of basal joint reconstruction and results in
extensive physiologic sensory restoration.

Disadvantages and Special Requirements


• This procedure narrows the palm.

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TECHNIQUE
• Pollicization refers to the neurovascular pedicle movement of a finger, often with its
metacarpal, for thumb reconstruction
• For congenital absence of the thumb, a simplified modification is recommended
• The index finger is basically recessed by resection of a segment of the second metacarpal
base, then pronated about 130 degrees and projected in palmar abduction at its fixed base.

Structures receive new identities:


- extensor digitorum communis  abductor
pollicis longus
- extensor indicis  extensor pollicis longus
- first dorsal interosseous  abductor pollicis
brevis
- first palmar interosseous  adductor pollicis
- metacarpal head and the proximal and middle
phalanges  trapezium and metacarpal and
proximal phalanges

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Grabb and Smith's Plastic Surgery, Seventh Edition by Charles H. Thorne, 2014
TOE-TO-THUMB TRANSFERS

Best Indication/Unique Advantages


• A toe-to-thumb transfer is performed when most of a wellcontrolled first metacarpal is
present but length is needed.
• Advantages include
(a) a good level of sensory recovery,
(b) bone growth continues, and
(c) that it is a single-stage operation.

Disadvantages and Special Requirements


• Foot disability may occur, and the thumb always looks like a toe.

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Grabb and Smith's Plastic Surgery, Seventh Edition by Charles H. Thorne, 2014
WRAPAROUND TOE TRANSFER

Best Indication/Unique Advantages


• For amputation near the MCP joint or distal to it, this is the procedure of choice.
• It results in the most normal-appearing reconstruction from the foot.

Disadvantages and Special Requirements


• This technically complex and demanding procedure results in limited functional
improvement when used without an MCP joint.
• It requires an iliac bone graft.

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TECHNIQUE

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Grabb and Smith's Plastic Surgery, Seventh Edition by Charles H. Thorne, 2014
REFERENCES
1. Littler JW. On making a thumb: one hundred years of surgical effort. J Hand Surg. 1976;1:35.
2. Goldner RD, Howson MP, Nunley JA, et al. One hundred eleven thumb amputations: replantation
vs. revision. Microsurgery. 1990;11:243.
3. Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast
Reconstr Surg. 1986;78:285.
4. MorrisonWA, O’Brien BM,MacLeod AM. Thumb reconstruction with a free neurovascular wrap-
around flap from the big toe. J Hand Surg. 1980;5:575.
5. Buck-Gramcko D. Thumb reconstruction by digital transposition. Orthop Clin North Am.
1977;8:329.
6. Stern PJ, Lister GD. Pollicization after traumatic amputation of the thumb. Clin Orthop.
1981;155:85.
7. May JW, Bartlett SP. Great toe-to-hand free tissue transfer for thumb reconstruction. Hand Clin.
1985;1:271.
8. Lipton HA,May JW, Simon SR. Preoperative and postoperative gait analyses of patients
undergoing great toe-to-thumb transfer. J Hand Surg. 1987;12:66. Copyright ©

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THANKS

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