Invited Discussion

The authors describe an extensive surgical procedure for reconstruction in a 27-year-old male whose ring finger was lost just proximal to the PIP joint. From the standpoint of hand function, the patient has a perfect grip of the fist and extension. However, he wanted the finger reconstructed-in this case, with a bone graft to elongate the finger and a combination of big toe and second toe wrap. The considerations were appearance, cosmesis, and length of extension. After reconstruction, when the patient makes a fist, in my opinion, the cosmesis has worsened because the finger is too long and will stick out in a grip position. For those who work with their hands, the finger will hinder hand function due to PIP and DIP stiffness. I am not sure this improves the usefulness of the hand, and the function is worse than in the previous condition.

However, if the patient really wants the finger to be longer and more functional, and is not willing to sacrifice the toe, there is a reconstructive solution. I would propose the second toe joint, including the PIP and possibly DIP joint, to attach to the ring finger, and the use of a big toe wrap-around flap with part of the distal phalanx and nail. This would serve to reconstruct the ring finger. The second toe could survive via the fibular site neurovascular bundle, and then be reconstructed by an iliac bone graft connecting the proximal to the distal phalanx. If the patient is not concerned about the second toe nail, this can be included with the vascular joint. The bone graft can be used to reconstruct the second toe, avoiding the big toe nail which is split.

As this case suggests, even if the PIP is combined with a DIP transfer, and subsequent iliac bone graft for second toe reconstruction is utilized, with a big toe wrap-around flap for the ring finger, there will still be a shortage of skin. A combined cross-finger flap may be necessary for reconstruction. In the reported case, a free groin flap was used for the donor; this is too bulky and requires defatting. The best coverage would be an arterialized venous flap. This is harvested from the foot or from the saphenous vein, creating a venous flap using arterial inflow and venous outflow.

In any case, the patient must sacrifice something if he really wants a reconstructed finger. The second toe for reconstruction of the ring finger is an alternative. In general, if the patient is in a stable condition, as far as function and cosmesis go, a prosthetic finger might be the best solution. Another technique would be ray amputation to eliminate the ring finger; this is a simple solution. If not acceptable, then a vascularized second toe PIP or combined DIP transfer with a big toe wrap-around flap, possibly combined with a cross-finger flap on the long finger, could be considered. The ring finger can be built up with the PIP and possibly DIP joint. This will produce sufficient length, cosmesis, size, and mobility, without sacrificing the toe.