|Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.|
|The use of vascularized joint transfer for reconstruction of absent joints with traumatic or congenital causes is well documented.1-18 Furthermore, it has been shown that, if harvested with an open epiphysis, longitudinal growth does occur in these transplants. 1,10,17 Thus, the vascularized joint transfer provides reconstruction with a natural joint surface and the possibility for both growth and pain-free functional range of motion. The joints may be harvested in whole or in part (see Chapter 1), but this discussion is limited to total joint transplant from the toes.
The indications for vascularized joint transfer include congenital deficiencies and traumatized joints in young patients or in failed implant arthroplasties where bone loss is extensive.2-7,9-13,15,17 Other authors have reported its use for temporomandibular joint reconstruction.
Tsai and colleagues have reported on their series and on the results of others.1,7-10,17 Joint transplants for pediatric trauma patients have better range of motion than in adult trauma patients. Both groups had greater range of motion than the congenital group.
The lack of better results in the congenital group was partly related to the consistently poor results in cases with no flexor tendon.
An important technical feature is the maintenance of a dorsal skin paddle, which allows for both monitoring of the flap and protection of the gliding tendon and joint capsule, which make adhesions less likely to occur. Furthermore, the skin paddle permits a tension-free closure, reducing the potential for vascular occlusion with postoperative edema.
Stable bony fixation ensures more rapid healing. We prefer to use a dowel technique combined with judiciously placed K-wires (see Technique).
The principal complications of vascularized toe joint transplant are infection and adhesion formation involving the tendon, the joint, or both.
The anatomy of the second and third toes was described previously (see Chapter 1) and will not be discussed in detail here.
The second toe's proximal interphalangeal and metatarsophalangeal joints are the most commonly chosen. The dissection is the same as in second-toe transplant. The arterial supply is usually based on the dorsal system (first dorsal metatarsal artery to the dorsal digits/arteries of the toe and its articular branches), but the plantar system may also be used.
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