TWO-STAGE RECONSTRUCTION OF FOUR-DIGIT AMPUTATION:DISTAL ULNAR ARTERY FLAP AND COMBINED SECOND- ANDTHIRD-TOE TRANSFER

MEHMET1 YILDIZ, M.D.,1* MUHITTIN SENER, M.D.,2

OLCAY TURGUTOGLU, M.D.,2 AND CELAL BAKI, M.D.2

We report a case of combined two toe transfer after distalulnar artery fasciocutaneous flap in a 10-year-old boy whohas four-digit amputation. Four years after the operation,satisfactory results were obtained both functionally

and cosmetically.

ª 2003 Wiley-Liss, Inc.

MICROSURGERY 23:103–104 2003

Multiple toe transfer to replace missing digits can beperformed either as two single-toe transfers harvestedfrom each foot, or as a combined second- and third-toetransfer harvested from the same foot.1

In this case report, we describe a boy with four-digitamputation of his dominant hand who was treated bycombined two-toe transfer harvested from the samefoot.

CASE REPORT

A 10-year-old boy was admitted to our emergencydepartment because of four-digit amputation at themetacarpal level; only the thumb was intact. The am-putated parts could not be replanted due to extensivedamage.

Two weeks later, as the first stage of reconstruction,a soft-tissue defect at the stump was closed by a distalulnar artery fasciacutaneous flap, after debridement andskin grafting had been applied to the donor site (Fig. 1).Since the axial-pattern vascularization of the flap wasbased on a cutaneous branch of the ulnar artery, byusing this flap, the major arterials of the hand were

preserved. As a result of providing soft-tissue support atthe stump, the risk of infection was eliminated, and thebackground for the second stage was prepared.

Five months later, in the second stage of recon-struction, a two-digit combined transfer from toe tohand was planned. After osseous stabilization, the flexorand2 extensor tendons were repaired. A. dorsalis pediswas anastomosed to A. radialis (end to end). Plantardigital nerves were anastomosed to the common digitalnerves. Only one large dorsal vein was anastomosed.

Postoperatively, the circulation was normal. Pinsthat were used to stabilize the second and third meta-tarses to the third and fourth metacarps were removedat the end of the sixth week, and then active exercise wasstarted. Fourteen weeks later, a capsulotomy was donedue to extension3 contracture of the MP joints.

A functional assessment was made 4 years afterreconstructive surgery (Fig. 2). Sensory recovery of

Figure 1. Stump was closed by distal ulnar artery fasciacutaneous

flap.

1Division of Hand Surgery, Department of Orthopaedics and Traumatology,School of Medicine, Karadeniz Technical University, Trabzon, Turkey

2Department of Orthopaedics and Traumatology, School of Medicine, Ka-radeniz Technical University, Trabzon, Turkey

*Correspondence to: Prof. Dr. Mehmet Yıldız, Ortopedi ve Travmatoloji ABD,Karadeniz Teknik Universitesi Tıp Fakultesi, 61080 Trabzon, Turkey.E-mail: myildiz@meds.ktu.edu.tr

Received 5 December 2002; Accepted 3 February 2003

Published online in Wiley InterScience (www.interscience.wiley.com).DOI:10.1002/micr.10101

ª 2003 Wiley-Liss, Inc.

both transferred fingers were good, with 3.61 Semmes-Weinstein monofilaments test. The active range ofmovement4 was 15� at the MP joint, 10� at the PIPjoint, and 10� at the DIP joint in both transferredfingers (Fig. 3). Tip pinch was 3.5 kg; on the normalside, it was 8 kg.

DISCUSSION

The distal ulnar artery flap is very reliable and sim-ple. It can cover the hand without the sacrifice of one of

the major perfusion axes. The main disadvantage of thisflap is its short pedicle and its relatively limited arc ofrotation.2

Although the second and third toes have been usedsimultaneously in a transplant and the results have beensatisfactory,3 a foot without two toes may be expected tohave considerable defects in function and appearance.4

In our case, the gait was normal (Fig. 4).Although the reconstruction might have been per-

formed as two single-toe transfers, we think that ourprocedure had the advantage of being relatively simple,since it needed only one arterial anastomosis; no inter-digital space reconstruction was required. On the otherhand, it had some disadvantages, e.g., the patient’s in-ability to move the digits independently, and shortnessof the digits.

REFERENCES

1. Yoshimura M. Multiple toe transplants in replacing missing digits.In:7 Pho RWH, editor. Microsurgical technique in orthopaedics.London: Butterworths; 1988. p 77�88.

2. Martin D, Bakhach J, Casoli V, Pellisier P, Llorens G, KhourtRK, Baudet J. Reconstruction of the hand with forearm islandflaps. Clin Plast Surg 1997;24:33�48.

3. Tsai T, Jupiter JB, Wolf TW, Atasoy E. Reconstruction of severetransmetacarpal mutilating hand injuries by combined second andthird toe transfer.8 J Hand Surg (Am) 1981;6:319�328.

4. Leung PC.Double toe transfer. J9 HandSurg (Br) 1987;12:162� 165.

Figure 4. Patient’s gait was normal.Figure 2. Appearance of transferred fingers on extension.

Figure 3. Functional result of reconstructed hand in pinch.

104 Yıldız et al.