Review
Vascularised toe proximal interphalangeal joint transfer in posttraumatic finger joint reconstruction: The effect of skin paddle design on extensor lag

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Summary

Vascularised joint transfer (VJT) from the toe proximal interphalangeal joint (PIPJ) has been criticised for providing a limited range of motion (ROM) and significant extensor lag in reconstructed digits. The original technique includes the dorsal skin of toe PIPJ as a marker of joint viability, while a modified technique uses the skin flap of the great toe and the dorsal foot. This systematic review aimed to assess vascularised toe-to-finger PIPJ transfers with respect to functional outcomes, and in particular, whether a modified skin paddle design can improve extensor lag.

Methods

A MEDLINE search was performed. Studies were included if they present five or more vascularised toe-to-finger PIPJ transfers for posttraumatic reconstruction, and with the functional outcome data available.

Results

Seven studies including 92 VJTs met the inclusion criteria. The overall survival rate was 93.5%. Among the successful 86 VJTs, mean single-joint ROM was 37.4 ± 21.1°, with a mean extension lag of 31.8 ± 18.8° and a mean flexion of 69.2 ± 22.8°. The traditional group with the skin paddle taken from the dorsum of the toe PIPJ had a statistically significantly greater extensor lag than the modified group with the skin paddle harvested from the great toe and dorsal foot (37.8° vs. 17.1°, p < 0.001). The secondary variable of interest was age of the patient at time of transfer (children vs. adults). There was no significant difference in ROM between younger (≤16 years) and older patients (>16 years).

Conclusions

This systematic review suggests that extensor lag may be improved by using the modified skin paddle design by harvesting it from the great toe and the dorsal foot. This effect may be mediated by the preservation of the native extensor tendon apparatus in the finger.

Section snippets

Literature search

A literature search was performed with the MEDLINE database. Two categorical searches were conducted using the medical subject heading terms: (1) “fingers/surgery”, “finger joint/surgery”, OR “finger injuries”; and (2) “toe joint/transplantation”, “joints/transplantation”, OR “toes/transplantation” and were combined using “AND”. A total of 247 citations were retrieved in October 2012. Relevant titles and abstracts of identified citations were assessed and the full text of all potentially

Study retrieval and study characteristics

Seven studies representing 92 vascularised toe-to-finger PIPJ transfers met the inclusion criteria, including six retrospective cases series and one cohort study (Figure 1).4, 7, 8, 9, 10, 11, 12 Most studies included different indications. Four studies reported anatomical prerequisites for the affected finger PIPJ. Ellis et al.,4 Chen et al.9 and Dautel et al.12 required good function of tendons. Kimori et al. included injured joints, in which the damage involved mainly the dorsal surface and

Addressing the problem of extensor lag in VJT

This systematic review showed that an overall ROM after vascularised toe-to-finger PIPJ transfer ranged from 31.8 to 69.2°. Due to the anatomic disparity between fingers and toes, the normal ROM of the toe PIPJ of all ages was narrower, with an average of 15–70°, resulting in an inherent shortage in ROM following VJT.13 Transferred toe PIPI joints can reach the maximal flexion limits of their native position, with an average of 69.2°. However, extensor lag becomes more pronounced after

Conclusion

This systematic review showed that vascularised toe-to-finger PIPJ transfer could provide acceptable functional ROM for posttraumatic reconstruction. In addition, we hope to provide surgeons with a guide to improve the functional ROM of VJT and broaden its clinical applications. This is the first study that critically compares the outcomes for different surgical techniques in vascularised toe-to-finger PIPJ transfer. Based on the results from this systematic review, we found that harvesting the

Conflict of interest statement

The authors have no financial interest to declare in relation to the content of this article.

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Presented at the Scientific Meeting of American Society for Reconstructive Microsurgery, in Las Vegas, NV, USA, 14–17 January 2012.

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