Taoyuan, Taiwan From the Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital and University.
Plast Reconstr Surg. 2012 Dec;130(6):810e-818e. doi: 10.1097/PRS.0b013e31826d1628.
Thumb amputations proximal to the metacarpophalangeal joint inevitably result in destruction of the thenar musculature and secondary loss of opposition. Opposable tripod pinch is one of the essential goals in toe-to-thumb reconstruction. Pronation osteosynthesis is the traditional method of restoring opposition, but a simultaneous opponensplasty may turn this static process into a dynamic one.
From 1992 to 2010, 19 toe-to-thumb transfers at and proximal to the metacarpophalangeal level with concomitant thenar muscle damage were examined. All underwent either pedicled groin flap (n = 16) or free flap (n = 3) surgery for amputation stump resurfacing. Nine transferred toes had a static opposition procedure with osteosynthesis by rotation of 30 to 60 degrees (group I). Ten transferred toes underwent an additional simultaneous opponensplasty to provide dynamic opposition (group II).
Seventy-eight percent (seven of nine) of group I and 100 percent of group II achieved opposable basic hand function and lateral pinch. In contrast, only 33 percent (three of nine) in group I regained tripod pinch grip compared with 90 percent (nine of 10) in group II, which was statistically significant (p = 0.02).
Primary opponensplasty in toe transfers provides active restoration of opposition and significantly better restoration of tripod pinch, in comparison with static opposition with osteosynthesis. It is therefore recommended that primary opponensplasty be performed at the time of toe transfer in such injuries.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
拇指近节指间关节的截肢必然导致大鱼际肌肉的破坏和继发性对掌功能丧失。可对指的三指夹捏是足趾-拇指重建的基本目标之一。旋前骨固定术是恢复对掌的传统方法，但同时行对掌肌成形术可使这个静态过程变为动态过程。
1992 年至 2010 年，我们检查了 19 例近节指间关节水平或近节指间关节以上的足趾-拇指转移术，这些患者均存在大鱼际肌肉损伤。所有患者均接受带蒂腹股沟皮瓣（n = 16）或游离皮瓣（n = 3）手术修复残端。9 个移植足趾行旋转 30 至 60 度的静态对掌固定术（I 组），10 个移植足趾同时行对掌肌成形术以提供动态对掌（II 组）。
I 组 78%（7/9）和 II 组 100%（10/10）获得可对指的基本手功能和侧方夹捏。相比之下，I 组仅 33%（9/27）恢复三指夹捏，而 II 组 90%（9/10）恢复三指夹捏，两组间差异有统计学意义（p = 0.02）。
与旋转固定术的静态对掌相比，在足趾转移术中行原发性对掌肌成形术可主动恢复对掌，并显著改善三指夹捏。因此，我们建议在这些损伤中进行足趾转移时同时行原发性对掌肌成形术。
临床问题/证据水平：治疗性，III 级。
