Thumb reconstruction with a wrap-around free flap according to the level of amputation

In 1980, Morrison and O'Brien reported their experiences with the reconstru ction of an amputated thumb using a wraparound neurovascular free flap from the great toe, but its indication has been limited distal to the metacarpo phalangeal (MP) joint (Morrison et al., J Hand Surg 5:575-583, 1980). We ha ve performed 37 wrap-around free flaps from the great toe for the reconstru ction of thumbs amputated at distal or proximal to the MP joint and investi gated their functional results according to the level of amputation. The am putation was distal and proximal to the MP joint in 25 and 12 cases, respec tively. Pinching and grasping power, two-point discrimination, and the amou nt of opposition to the other fingers were compared to the uninjured hand. Pinching and grasping power were not significantly different according to t he level of amputation but the results of two-point discrimination was bett er in the cases amputated proximal to the MP joint. The opposition of recon structed thumb to the other fingers was completely possible in all cases am putated distal to the MP joint. In the 12 cases amputated proximal to the M P joint of the thumb, opposition was completely possible in 6 cases in whic h the iliac bone block was fixated in the position of 30 degrees flexion an d 45 degrees internal rotation. However, in the other six cases in the fixa tion of 30 degrees flexion and 30 degrees internal rotation, the opposition of the reconstructed thumb to the ring and little fingers was impossible i n five cases and only to the little finger in one case. In this study, we c oncluded that amputation proximal to the MP joint is not an absolute contra indication to the wrap-around free flap procedure for thumb reconstruction. However, for a better functional outcome, we recommend iliac bone block fi xation in the position of 30 degrees flexion and 45 degrees internal rotati on. (C) 2000 Wiley-Liss, Inc.