Nonvascularized Toe Joint Transfers to the Hand in Young Children: Technique Revisited

Abstract

Background: Small joint reconstruction of the hand poses a significant challenge, especially in children where both functional motion and preservation of the epiphysis are desired. Auto-transplantation of whole joints is the only way to reconstruct a functional joint that maintains growth potential. Historically, nonvascularized toe-to-finger joint transfer has been criticized for high rates of avascular necrosis and joint dissolution, while vascularized transfers seemingly resulted in increased durability of the joint space and epiphysis. However, certain populations remain poor candidates for microvascular reconstruction, such as those with congenital deformities or sequelae from trauma or infection. In our case series, we demonstrate that a simplified nonvascularized surgical technique and careful patient selection can produce stable, functional joints. Methods: Nonvascularized toe-to-finger joint transfer was performed in 3 children between the ages of 4 and 6. Reconstructed joints included 2 proximal interphalangeal (PIP) joints and 1 metacarpophalangeal (MCP) joint. Donor grafts consisted of second toe PIP joints harvested en bloc to include the epiphysis of the middle phalanx, collateral ligaments, volar plate, and a diamond-shaped island of extensor tendon with its central slip attachment. Results: Follow-up ranged from 7 to 29 months. Each patient demonstrated functional improvements in joint motion and stability. Postoperative radiographs confirmed adequate joint alignment and persistence of the joint spaces. Epiphyseal closure was observed in 1 patient as early as 25 months postoperatively. Conclusions: Nonvascularized joint transfer should remain a practical consideration for small joint reconstruction of the hand in certain pediatric patients.

A Systematic Review of Vascularized Toe and Non-Vascularized Toe Phalangeal Transfer for Reconstruction of Congenital Absence of Digits or Thumb”

“…11,27–30 In the study by Radocha et al, all three transfers in which phalangeal resection was performed subperiosteally resorbed within 12 months, and only periosteum-covered bone grafts showed complete take in the study by Unglaub et al 11,29 All nonvascularized toe phalanges should be harvested extraperiosteally along with their collateral ligaments to maximize survival and growth. 4,10,11,20,21,28,29,31–36 We also found a higher success rate with extraperiosteal harvest ( P < 0.0001) in the present study. Additional studies that follow these cases to skeletal maturity would provide more complete data on the resorption rate in this population of patients.…”

“…2,3 Nonvascularized toe phalanx transplantation was the first technique, although historically it has incurred high rates of avascular necrosis. 4 However, nonvascularized free toe phalangeal grafts are still often used to lengthen short fingers, with adequate soft-tissue coverage. 2 The indications for vascularized toe-to-hand transfer depend on adequate vasculature and the morphologic anatomy of children with absent digits or thumbs.…”

Metacarpophalangeal Joint Reconstruction by Vascularized Partial Metatarsophalangeal Joint Transplantation

“…Vascularized complete joint transplantation is desirable because it does not alter the internal milieu of the joint, and the joint surfaces remain congruent 1 . The only articles on nonvascularized joint transplantation we could find were for pediatric patients or for transplantation of a part of one component surface of the joint 5,6 . The advantages of vascularized complete joint transplantation with maintenance of hyaline cartilage and presentation of joint space were better demonstrated than those of nonvascularized joint transplantation in animal experiments 7,8 .…”