A Novel Preoperative Planning Technique Using a Combination of CT Angiography and Three-Dimensional Printing for Complex Toe-to-Hand Reconstruction

Abstract

Background Microsurgical toe-to-hand transplantation is a reasonable salvage procedure after failed replantation, though no consensus exists on proper donor toe length for restoration of hand function and optimal donor flap needed for recipient site healing. The purpose of this study was to introduce a novel technique for preoperative planning in complicated toe-to-hand reconstruction and to assess feasibility in four cases.

Methods Computed tomography (CT) angiography was used to map donor site vasculature, whereas CT data were used to create three-dimensional (3D) soft tissue and skeletal models for injured and uninjured hands. Based on the reformatted model (mirror of uninjured hand), soft tissue and finger skeleton models were generated using a 3D printer. An adhesive plaster model was placed on the donor site to determine osteotomy level and incision markings. The skeletal model was used to determine the length of the donor foot resection. Four complex amputation cases were included to illustrate clinical feasibility and early functional and cosmetic outcomes.

Results In all four cases, thumb and fingers were reconstructed successfully and all flaps survived. No arterial or venous thrombosis or major donor morbidity were observed. Functional and cosmetic outcomes were satisfactory with similarly satisfactory static two-point discrimination, key pinch and grip strength, and Michigan Hand Outcomes Questionnaire scores.

Conclusion This novel microsurgical toe-to-hand reconstruction methodology, as introduced in this study, showed promising functional and cosmetic outcomes. Application of this technique in complex hand injuries has the potential to increase surgical efficiency, minimize procedural morbidity, and improve reproducibility.

Keywords

microsurgery - toe-to-hand - transfer - computed tomography angiography - CT surgical planning

• References

• 1 Michon J, Merle M, Bouchon Y, Foucher G. Functional comparison between pollicization and toe-to-hand transfer for thumb reconstruction. J Reconstr Microsurg 1984; 1 (2) 103-112
• 2 Henry SL, Wei F-C. Thumb reconstruction with toe transfer. J Hand Microsurg 2010; 2 (2) 72-78
• 3 Cobbett JR. Free digital transfer. Report of a case of transfer of a great toe to replace an amputated thumb. J Bone Joint Surg Br 1969; 51 (4) 677-679
• 4 Waljee JF, Chung KC. Toe-to-hand transfer: evolving indications and relevant outcomes. J Hand Surg Am 2013; 38 (7) 1431-1434
• 5 Fadero PE, Shah M. Three dimensional (3D) modelling and surgical planning in trauma and orthopaedics. Surgeon 2014; 12 (6) 328-333
• 6 Park S, Han SH, Lee TJ. Algorithm for recipient vessel selection in free tissue transfer to the lower extremity. Plast Reconstr Surg 1999; 103 (7) 1937-1948
• 7 May Jr JW, Athanasoulis CA, Donelan MB. Preoperative magnification angiography of donor and recipient sites for clinical free transfer of flaps or digits. Plast Reconstr Surg 1979; 64 (4) 483-490
• 8 Buncke GM, Buncke HJ, Lee CK. Great toe-to-thumb microvascular transplantation after traumatic amputation. Hand Clin 2007; 23 (1) 105-115
• 9 Akashi M, Nomura T, Sakakibara S, Sakakibara A, Hashikawa K. Preoperative MR angiography for free fibula osteocutaneous flap transfer. Microsurgery 2013; 33 (6) 454-459
• 10 Hutchinson DT. Color duplex imaging. Applications to upper-extremity and microvascular surgery. Hand Clin 1993; 9 (1) 47-57
• 11 Rozen WM, Stella DL, Ashton MW, Phillips TJ, Taylor GI. Three-dimensional CT angiography: a new technique for imaging microvascular anatomy. Clin Anat 2007; 20 (8) 1001-1003
• 12 Lee GK, Fox PM, Riboh J , et al. Computed tomography angiography in microsurgery: indications, clinical utility, and pitfalls. Eplasty 2013; 13: e42
• 13 del Piñal F. The indications for toe transfer after “minor” finger injuries. J Hand Surg [Br] 2004; 29 (2) 120-129
• 14 Tsai TM, D'Agostino L, Fang YS, Tien H. Compound flap from the great toe and vascularized joints from the second toe for posttraumatic thumb reconstruction at the level of the proximal metacarpal bone. Microsurgery 2009; 29 (3) 178-183
• 15 Koshima I, Inagawa K, Urushibara K, Okumoto K, Moriguchi T. Fingertip reconstructions using partial-toe transfers. Plast Reconstr Surg 2000; 105 (5) 1666-1674
• 16 Kotkansalo T, Vilkki S, Elo P. Long-term results of finger reconstruction with microvascular toe transfers after trauma. J Plast Reconstr Aesthet Surg 2011; 64 (10) 1291-1299
• 17 Woo S-H, Lee G-J, Kim K-C, Ha S-H, Kim J-S. Immediate partial great toe transfer for the reconstruction of composite defects of the distal thumb. Plast Reconstr Surg 2006; 117 (6) 1906-1915
• 18 Gabrielli C, Olave E. Origins of the dorsal metatarsal arteries in humans. Scand J Plast Reconstr Surg Hand Surg 2002; 36 (4) 221-225
• 19 Mathes DW, Neligan PC. Current techniques in preoperative imaging for abdomen-based perforator flap microsurgical breast reconstruction. J Reconstr Microsurg 2010; 26 (1) 3-10
• 20 Lee BT. Imaging modalities in perforator flap reconstruction. J Reconstr Microsurg 2010; 26 (1) 1
• 21 Masia J, Kosutic D, Cervelli D, Clavero JA, Monill JM, Pons G. In search of the ideal method in perforator mapping: noncontrast magnetic resonance imaging. J Reconstr Microsurg 2010; 26 (1) 29-35
• 22 Pratt GF, Rozen WM, Chubb D, Ashton MW, Alonso-Burgos A, Whitaker IS. Preoperative imaging for perforator flaps in reconstructive surgery: a systematic review of the evidence for current techniques. Ann Plast Surg 2012; 69 (1) 3-9
• 23 Hijjawi JB, Blondeel PN. Advancing deep inferior epigastric artery perforator flap breast reconstruction through multidetector row computed tomography: an evolution in preoperative imaging. J Reconstr Microsurg 2010; 26 (1) 11-20
• 24 Schweizer A, Fürnstahl P, Nagy L. Three-dimensional correction of distal radius intra-articular malunions using patient-specific drill guides. J Hand Surg Am 2013; 38 (12) 2339-2347
• 25 Merc M, Drstvensek I, Vogrin M, Brajlih T, Recnik G. A multi-level rapid prototyping drill guide template reduces the perforation risk of pedicle screw placement in the lumbar and sacral spine. Arch Orthop Trauma Surg 2013; 133 (7) 893-899
• 26 Rengier F, Mehndiratta A, von Tengg-Kobligk H , et al. 3D printing based on imaging data: review of medical applications. Int J CARS 2010; 5 (4) 335-341
• 27 Zhang YZ, Chen B, Lu S , et al. Preliminary application of computer-assisted patient-specific acetabular navigational template for total hip arthroplasty in adult single development dysplasia of the hip. Int J Med Robot 2011; 7 (4) 469-474
• 28 Gerstle TL, Ibrahim AM, Kim PS, Lee BT, Lin SJ. A plastic surgery application in evolution: three-dimensional printing. Plast Reconstr Surg 2014; 133 (2) 446-451
• 29 Giessler GA, Schmidt AB, Germann G, Pelzer M. The role of fabricated chimeric free flaps in reconstruction of devastating hand and forearm injuries. J Reconstr Microsurg 2011; 27 (9) 567-573
• 30 Yıldız M, Şener M, Turgutoğlu O, Baki C. Two-stage reconstruction of four-digit amputation: distal ulnar artery flap and combined second- and third-toe transfer. Microsurgery 2003; 23 (2) 103-104
• 31 del Piñal F, García-Bernal FJ, Delgado J, Regalado J, Sanmartín M, García-Fernández D. Overcoming soft-tissue deficiency in toe-to-hand transfer using a dorsalis pedis fasciosubcutaneous toe free flap: Surgical technique. J Hand Surg Am 2005; 30 (1) 111-119
• 32 Weinand C, Gupta R, Weinberg E , et al. Toward regenerating a human thumb in situ. Tissue Eng Part A 2009; 15 (9) 2605-2615