Nail reconstruction using an osteo-onychocutaneous flap with the dorsal digital artery of the hallux as the pedicle: Techniques and anatomical insights

Abstract

Nail reconstruction with preserved pulp tissue can be challenging due to the use of oversized flaps, and nail deformities often resulting from bone resorption. This study describes a novel technique using the dorsal digital artery of the hallux as a pedicle for an osteo-onychocutaneous flap. A preoperative handheld Doppler was used to identify the course of the dorsal digital artery, and intraoperatively, the flap was elevated without disturbing the plantar tissue, thereby minimizing the risk of foot complications. A prospective study was conducted on all partial toe transplantation cases between September 2020 and March 2023 to analyze the anatomical variations of the dorsal digital artery. Thirty-one patients were included in the study. The dorsal digital artery was successfully identified preoperatively and confirmed intraoperatively in all cases. It branched from the first dorsal metatarsal artery in 24 cases and the plantar digital artery in seven cases. The branching location was found to be 24.3 ± 4.5 mm proximal to the web in the former group and 3.9 ± 3.9 mm (p < 0.001) in the latter group. The vascular diameter at the branching site was measured to be 0.8 ± 0.2 mm, with no significant difference based on the location. Nail reconstruction procedures were successfully performed using this flap for defects in the thumb, index finger, and little finger. Stable nails were reconstructed in all cases with minimal foot complications. In conclusion, this technique offers a reliable approach to nail reconstruction, minimizing donor site morbidity and preserving natural nail morphology.