Bachleitner K, Blank B, Klein S, Geis S, Aung T, Prantl L, Dolderer J H
Department of Plastic-, Hand- and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany.
Department of Plastic-, Reconstructive- und Hand Surgery, Burn Center, University Hospital of Paracelsus Medical Private University Nuernberg, Germany.
Clin Hemorheol Microcirc. 2016;64(3):333-344. doi: 10.3233/CH-168100.
The reconstruction of metacarpal- and interphalangeal joints after severe hand injuries has been proven to be challenging. Commonly used procedures like arthrodesis, amputation or ray resection of the finger compromise the functionality of the injured finger. Especially for young patients, the restoration of all functions of the fingers is a priority. Local tissue transfers for finger joint reconstructions is not an option due to inacceptable donor site morbidity; microsurgical tissue transfers in terms of free toe joint transfers have proven to be a valuable method.
We present the case of a patient who suffered an excessive injury from a circular saw to his dominant hand. The MCP Joints of D2-D4 were fully destroyed, along with the PIP joint of a subtotally amputated D4. Arteries, nerves and tendons could be coapted directly, while primarily reconstructing of the finger joints was impossible. To ensure a possible regain of full functionality, two coherent joints, the MTP and the PIP of one toe, were transferred to the ring finger as a single transplant, reconstructing the MCP and the PIP joints of the injured finger in a one step procedure. Additionally the MCP joint of the D2 was reconstructed by the use of a free PIP-joint transfer, further the MCP joint of the D3 was replaced by an MCP endoprosthesis.
After a follow up of 3 years the patient displayed full function of his dominant hand including sensitivity, and has gone back to manual work without limitations. The result was cosmetically acceptable and the donor site defect was easily being tolerated by the patient who is playing soccer in the regional soccer league.
Free double toe joint transfer has been proven feasible in this patient. While transferring a single toe joint to reconstruct a finger joint is a well-established method, our review of the latest literature showed no case of a free transfer of two coherent joints and three transplanted joints in one hand. The applied microsurgical technique should be considered by microsurgically trained hand surgeons for the treatment of comparable severe hand injuries. In comparison to the most common procedures described for the repair and reconstruction of severely injured finger joints this method showed superior results.
严重手部损伤后掌指关节和指间关节的重建已被证明具有挑战性。常用的手术方法，如关节融合术、截肢或手指射线切除术，会损害受伤手指的功能。特别是对于年轻患者，恢复手指的所有功能是首要任务。由于供区并发症不可接受，手指关节重建采用局部组织转移不是一个选择；游离趾关节转移的显微外科组织转移已被证明是一种有价值的方法。
我们报告一例患者，其优势手被圆锯严重割伤。示指至环指的掌指关节完全损毁，同时环指近节指骨部分离断伴近侧指间关节损伤。动脉、神经和肌腱可直接吻合，而手指关节的一期重建无法进行。为确保可能恢复全部功能，将一个趾的一个跖趾关节和一个近侧指间关节作为单个移植物转移至环指，一步重建受伤手指的掌指关节和近侧指间关节。此外，示指的掌指关节通过游离近侧指间关节转移进行重建，中指的掌指关节则用掌指关节假体置换。
随访3年后，患者优势手功能完全恢复，包括感觉功能，已无限制地重返体力工作。结果在外观上可接受，供区缺损对于参加地区足球联赛的患者来说易于耐受。
游离双趾关节转移在该患者中已被证明是可行的。虽然转移单个趾关节重建手指关节是一种成熟的方法，但我们对最新文献的回顾显示，尚无一手游离转移两个连贯关节和三个移植关节的病例。经过显微外科培训的手外科医生在治疗类似严重手部损伤时应考虑应用这种显微外科技术。与描述的用于严重受伤手指关节修复和重建的最常见手术方法相比，该方法显示出更好的效果。
