A retrospective review of the authors’ 15 year experience with digital reconstruction using a free toe wrap-around procedure is presented. From 1983-1998, 16 toe wrap-around procedures were performed, after the technique described by Morrison et al, 1980. Patients ranged in age from 18-46 years and 14/16 cases involved thumb reconstruction. Five of 16 defects involved soft-tissue alone, and 11/16 involved bony defects in addition. Preoperative angiography was performed on both the recipient and the donor sites in all patients. Results were assessed with thumb opposition to fingertips, strength, range of motion, and 2-point discrimination. Serial radiographs were evaluated to document the stability and durability of the iliac crest bicortical grafts. Technical variations involved subperiosteal dissection of the nail matrix without bone from the donor site, conically shaped bicortical iliac crest grafts to mimic phalangeal shape, and donor site closure with a cross-toe flap and skin graft from the second toe. Fourteen of sixteen flaps were successful at an average follow-up of 38 months. Pinch strength in the thumb reconstructions averaged 51% of the opposite hand. Two-point discrimination averaged 7.6 mm. Average motion at the thumb IP joint measured 49 degrees, although 8/16 (50%) patients required secondary surgery to augment mobility. Mean bone graft resorption measured 13% in width and 9% in length. No malunions occurred. Complications included two flap losses, partial skin necrosis in 2/16, and cold intolerance in 1/16 transfers. There were no donor site complications reported.
The authors present a large experience of digital reconstruction after amputation using a great toe wrap-around procedure. The results are comparable to the best series of great and second toe transfers and support the viability of this procedure as an alternative to toe transplantation. The functional and cosmetic results were adequate, and the absence of donor site complications is especially notable. Further description of their cross-toe reconstruction of the donor site would be helpful, as this appears to have offered better results than simple skin grafting alone, as presented in other series.