Reconstruction of the avulsed thumb with nonmicrosurgical techniques – functional and aesthetic results

Abstract

Introduction. The thumb accounts for almost 50% of hand function, the pulp having a major role in ensuring it. Avulsed injuries lead to disability, so preserving length, position, mobility, sensitivity of the thumb are main goals that must be fulfilled for the techniques used in reconstruction of the thumb and its pulp. Aim of the study. To evaluate the outcomes of the reconstruction in the emergency of the amputated thumb using isolated or associated homodigital and heterodigital flap techniques in those situations when microsurgical replantation is not possible due to local or general conditions. The study is based on the evaluation of the functional (thumb length, sensitivity, motility active joint movement and cortical reintegration) and aesthetic outcomes. Materials and methods. Twenty-eight patients aged between 18 and 65 years old, with complete posttraumatic amputation of the thumb at the level of interphalangeal joint or proximal phalanx were evaluated. The aim of reconstruction was to achieve a thumb of proper length, good sensitivity, motility and cortical reintegration of the new pulp. In 6 cases, the reconstruction was done using the Mantero-Bertolotti technique with an O’Brien flap, and in 6 cases the use of a single heterodigital neurovascular Littler flap was sufficient. The association of the two techniques with a Littler’s flap instead of the O’Brien flap in the Mantero-Bertolotti reconstruction was the choice in 14 patients. In other 2 cases the reconstruction algorithm included the use of a Foucher (cerf-volant), Simonetta or Hueston flap. Results. The results have been evaluated based on age, injury complexity, size of the flap, mobility, sensitivity, cortical reintegration of the new pulp. The best average range of motion of the new thumb in those cases in which we applied the associated technique (Littler’s flap instead of the O’Brien flap in the Mantero-Bertolotti reconstruction) using Kapandji score (8 score). Regarding the sensibility, we achieved a protective sensibility of the new thumb. At the two point discrimination test (2PD test), the results were between 7 – 11 mm. At the light touch deep pressure test (SW test), all the patients felt the blue monofilament and 24 out of 30 felt the violet monofilament. Conclusions. The use of isolated or combined homodigital and heterodigital, flap techniques is a proper choice for reconstructing the avulsed thumb in those cases when the microsurgical replantation is not possible. The microsurgical replantantion remains the gold standard in thumb amputation.