Long-Term Results after Vascularized Joint Transfer for Long Finger Joint Reconstruction

Vascularized complete joint transfer from the finger or the second toe offers the unique possibility of reconstructing a joint defect at the thumb or fingers using autologous tissue, which fully preserves growth potential. Vascularized joint transfer in children is indicated because of the lack of therapy options offering normal growth potential. In adults, vascularized joint transfer is indicated in cases of contraindication for prosthetic joint replacement or arthrodesis.

In a retrospective clinical study, 14 vascularized joint transfers to the hand with an average follow-up of 8.2 (3 to 15) years were evaluated. The finger joint defect was caused by trauma in 11 patients and infection, tumor, and congenital deformity in 1 patient each. There were 12 men and 2 women. The mean age was 26 (2 to 42) years. In 4 cases, a partial vascularized joint transfer was carried out, with the transplant being harvested in two cases from a non-replantable finger, according to the “tissue bank concept” of Chase, and in the other two cases from the PIP-joint of the second toe. In 10 patients, a complete vascularized joint transfer was carried out, with the joint being harvested from the hand in 6 cases and from the second toe in 4 cases.

The following criteria were evaluated: active range of motion (neutral-0-method), postoperative arthritis, growth and complications.

Active range of motion of the transplanted joint was for partial PIP-joint transfer Ex/Flex 0/20°/65° and for partial MP joint transfer, 0/20°/30°. After DIP-to PIP joint transposition, active range of motion was measured: Ex/Flex 0/20°/60°, after PIP-to-PIP transposition, 0/30°/60°, PIP-to-MP-transposition, 0/20°/80° and after MP-to-MP-transposition, 0/20°/57°. The results after microvascular PIP joint transfer from the second toe for PIP joint reconstruction were 0/25°/58° for PIP-joint reconstruction, and 0/15°/70° for MP joint reconstruction.

Arthritic changes could be seen in 3 of 4 patients with partial vascularized joint transfer. In all complete joint transfers, there was no clinical or radiological evidence of arthritis, even after 15 years. In the two skeletally immature patients at the time of transfer, normal growth compared to the contralateral donor site could be seen. In 8 of 14 patients, complications occurred. In 4 cases, tendolysis of the extensor tendon was necessary. In 4 patients, skeletal malalignement (3 ×  sagital plane, 1 × rotation) was diagnosed. In one patient, flexor pulley reconstruction was necessary in order to correct a bowstring deformity.

Whenever possible, the “tissue-bank-concept,” according to Chase, should be applied in finger joint reconstruction, using a vascularized joint graft from either an amputated or a worthless digit. Results of vascularized joint transfer have to be compared to those of persistent joint defect, prosthetic joint replacement, arthrodesis, or ultimate amputation of the finger involved. Patients in whom a vascularized joint transfer is anticipated should be informed about the following points: 1) the risk of failure (vascular failure, tendon adhesion, joint stiffness, etc.) is about 10%; and 2) the expected active range of motion that depends on etiology, age, donor site, and recipient site. Traumatic joint defects show a greater active range of motion than congenital defects. Children do have more active joint motion than adults. 3) Because of minor donor site impairment and rapid recovery of normal gait, the whole second ray should be amputated after harvesting of a joint graft at the second toe. 4) Hospitalization takes 2 to 3 weeks. Immobilization of the hand (palmar forearm splint) and the foot (lower leg cast) should be applied for 4 to 6 weeks. Intensive physical therapy is necessary for at least 3 months. Additional splinting is advised for about 6 months. 5) Extensor tendolysis is necessary in a large number of cases but should not be done earlier than 6 months after transplantation.