Reconstruction of severe composite tissue defects of the hand using a composite second metatarsal flap

Dear Sir,

Because of the similarities between the anatomy of the hand and foot, toes are suitable donors for reconstruction of finger defects (Adani and Woo, 2017; Balan, 2016; Graham et al., 2016). Here, we report the reconstruction of severe composite tissue defects of the hand using a composite second metatarsal flap.

A 22-year-old man was transferred to our hospital, 24 hours after having his left hand severely injured in a car accident. Initial wound assessment indicated that the abductor pollicis brevis, flexor pollicis brevis and opponens pollicis muscle were missing. The palmaris longus, flexor pollicis longus and flexor carpi radialis tendons, as well as the flexor digitorum superficialis tendon of the index finger, flexor retinaculum and median nerve were partially damaged. Almost 2/3 of the first metacarpophalangeal joint, 4/5 of the first metacarpal, most of the trapezium, 2/3 of the scaphoid and part of the radial styloid were lost. The metacarpophalangeal joint, carpometacarpal joint and wrist joint had been fixed with Kirchner wires at a local hospital.

Vacuum sealing drainage treatment was administered until the bruises on the finger pulp and palm were healed. The reconstructive surgery was performed 23 days after injury. A composite second metatarsal flap was designed and outlined on the left foot (Figure 1(a)). The entire second metatarsal, second toe, dorsalis pedis artery and saphenous vein were raised as a flap (Figure 1(b)). The donor site was closed with a skin graft from the abdomen. OPEN IN VIEWER

The flap was placed inversely to the recipient site (Figure 1(b)), and the reconstruction work took place as follows.

Joint reconstruction. Part of the metatarsal and 1/3 of its cortex was excised with an electric saw and then attached to the remnant metacarpal inversely by wire suture. The proximal phalanx of the toe was fixed to the remnant scaphoid using a Herbert cannulated screw. The middle phalanx was fixed on radial styloid with cortical bone anchors, and the distal phalanx was amputated (Figure 1(c)).

The skin was closed loosely. The patient received anticoagulant, anti-inflammatory and antispasmodic therapy for 7 days and kept his hand and foot elevated. The hand was immobilized for 3 weeks, followed by progressive physical therapy.

The flap survived completely (Figure 2(a) and (b)). By 8 months after surgery, the pinch function of the thumb was partially restored, as the thumb could touch the tips of the index, middle and ring fingers effortlessly (Figure 2(c)). The two-point discrimination on the flap was 12 mm and on the thumb pulp was 6 mm. The donor site also recovered well (Figure 2(d)). The patient was satisfied with the functional and cosmetic results. OPEN IN VIEWER