Long-term results after vascularised joint transfer for finger joint reconstruction.

INTRODUCTION

Vascularised complete joint transfer from the finger or the second toe offers the unique possibility of reconstructing a joint defect on the thumb or fingers using autologous tissue, which fully preserves its growth potential. Indications for vascularised joint transfer on the finger in children are set because of lack of therapy options offering normal growth potential. In adults vascularised joint transfer is indicated in case of contraindication for prosthetic joint replacement or arthrodesis.

PATIENTS AND METHODS

In a retrospective clinical study 16 vascularised joint transfers to the hand with an average follow up of 8.2 (3-15) years were evaluated. The finger joint defect was caused by trauma in 12 patients, tumour in two patients and infection and congenital deformity in one patient each. There were 14 men and two women. The mean age range was 26 (2-42) years. In six cases a partial vascularised joint transfer was carried out, with the transplant being harvested in two cases from a nonreplantable finger according to the 'tissue bank concept' according to Chase and in the other two cases from the proximal interphalangeal (PIP)-joint of the second toe. In 10 patients a complete vascularised joint transfer was carried out, with the joint being harvested from the hand in six cases and from the 2nd toe in four cases. The following criteria were evaluated: active range of motion (Neutral-0-Method), postoperative arthritis, growth and complications.

RESULTS

The active range of motion of the transplanted joint for partial PIP joint transfer ex/flex was 0/20 degrees /65 degrees and for partial metacarpo-phalangeal (MP) joint transfer 0/20 degrees /30 degrees. After distal interphalangeal (DIP)-to-PIP joint transposition the active range of motion was measured as ex/flex 0/20 degrees /60 degrees, after PIP-to-PIP transposition 0/30 degrees /60 degrees, PIP-to-MP transposition 0/20 degrees /80 degrees and after MP-to-MP transposition 0/20 degrees /57 degrees. The results after microvascular PIP joint transfer from the 2nd toe for PIP joint reconstruction were 0/25 degrees /58 degrees for PIP joint reconstruction and 0/15 degrees /70 degrees for MP joint reconstruction. Arthritic changes could be seen in three out of four patients with partial vascularised joint transfer. In all complete joint transfers there was no clinical and radiological evidence of arthritis even after 15 years. In the two skeletally immature patients at the time of transfer, normal growth compared to the contralateral donor site could be seen. In eight out of 16 patients complications occurred. In four cases tendolysis of the extensor tendon was necessary. In four patients skeletal misalignment (3 x sagittal plane, 1 x rotation) was diagnosed. In one patient flexor pulley reconstruction was necessary in order to correct a bowstring deformity.

CONCLUSIONS

Whenever possible the 'tissue bank concept' according to CHASE should be applied in finger joint reconstruction using a vascularised joint graft from either an amputated or a redundant digit. Results of vascularised joint transfer have to be compared to those of persisting joint defect, prosthetic joint replacement, arthrodesis, or ultimately amputation of the finger involved. Patients in whom a vascularised joint transfer is anticipated should be informed about the following points: (1) The risk of failure (vascular failure, tendon adhesion, joint stiffness, etc.) is about 10%. (2) The expected active range of motion depends on aetiology, age, donor site and recipient site. Traumatic joint defects show a greater active range of motion than congenital defects. Children have more active joint motion than adults. (3) Because of minor donor site impairment and rapid recovery of normal gait the whole second ray should be amputated after harvesting of a joint graft on the second toe. (4) Hospitalisation takes 1-2 weeks. Immobilisation of the hand (palmar forearm splint) and the foot (lower leg cast) should be applied for 4 to 6 weeks. Intensive physiotherapy is necessary for at least 3 months. Additional splinting is advised for about 6 months. (5) Extensor tendolysis is necessary in a large number of cases but should not be done earlier than 6 months after transplantation.