Immediate partial great toe transfer for the reconstruction of composite defects of the distal thumb

BACKGROUND

Thumb defects distal to the interphalangeal joint do not cause any disability; therefore, any consideration to reconstruct the thumb is governed by the lifestyle and cultural background of the patient. This study presents the excellent results achieved by immediate partial great toe-to-hand transfer to reconstruct acute composite defects of the distal thumb.

METHODS

Fifty-three patients with amputation or crush injury of the distal thumb who underwent partial great toe-to-hand transfer at the authors' institute over an 11-year period were reviewed. Based on the amputation level of the distal thumb, the authors classified the injuries into three groups. Operative techniques used were osteo-onychocutaneous flap with partial or whole toenail from the great toe and partial great toe transfer with arthrodesis of the interphalangeal joint. Overall results were evaluated in terms of success rate, incidence of emergency reexploration, and number and type of secondary operation. Static two-point discrimination, range of motion, pinch strength, and subjective satisfaction were also evaluated.

RESULTS

The success rate of immediate partial great toe-to-hand transfer was 100 percent. The incidence of inflammation and the reexploration rate were not significantly different from those in previously reported articles. In 35 cases where postoperative follow-up was possible, static two-point discrimination, total active range of motion, and pinch strength were generally excellent and the majority of the patients were satisfied with the final outcome.

CONCLUSION

Immediate reconstruction with partial great toe transfer is an excellent option for reconstruction of composite defects of the distal thumb, not only for aesthetic reasons but also for functional purposes.

Toe-to-hand transplantation surgery

This article discusses toe-to-hand transplantation. The purpose of this article is to familiarize nurses with this procedure. In many cases, the actions taken initially and postoperatively may have a direct effect on the success or failure of the surgery. Two different procedures are discussed. The first procedure is replantation or revascularization of amputated digits in which time is of the essence and is usually performed right after the initial injury. The second procedure is the toe-to-hand transfer, which is an elective procedure in which there is less emphasis on time. This procedure occurs a few months after the initial accident.

Cosmetic reconstruction of distal finger absence with partial second toe transfer

The authors successfully performed a series of 32 distal finger reconstructions using partial second toe-to-finger transfers solely for aesthetic indications. The resulting hand function shows an average static 2-point discrimination of 8 mm. Total active range of motion was 205 degrees. Key-pinch strength and grip strength averaged 65 and 90% of the normal contralateral side, respectively. Patient satisfaction, as reflected by the average subjective satisfaction scores for aesthetic appearance and function (SSSAF) of the reconstructed distal finger, was high at 82 and 78, respectively. The SSSAF for the donor site averaged 88 for function and 75-80 for aesthetic appearance, which is statistically significant (p<0.05). The authors modified the technique of distal finger reconstruction using second toe transfers in three ways. One is to skeletonize the neurovascular bundle of the harvested toe and pass it through a subcutaneous tunnel between the distal finger incision and the web space incision to avoid lengthy and unsightly scars on the reconstructed finger. Another is to defat the skin flaps developed at the amputated stump and to use a zigzag incision on the toe flap to create a smoother skin junction between the stump and the transferred toe. The third refinement is to perform the arterial microanastomosis at the level of the web space to take advantage of the larger diameter of the vessels in this area. Cosmetic reconstruction of the distal finger with a partial second toe-to-hand transfer provides a high degree of patient satisfaction, both aesthetically and functionally.

Recovery of disused replanted digits by second toe hemipulp flap transfer

BACKGROUND

Amputation of the distal phalanx is the most common among all mutilation injuries. Generally, it has been believed that the prognosis of this type of amputation is satisfactory; however, disuse of digits because of severe atrophy and sensory disturbances is frequently observed in the follow-up period.

METHODS

The authors intended to use the second toe hemipulp flap for recovery of these disused digits and transferred the flaps to eight severely atrophic postreplanted digits. Objective sensory recovery was assessed along with estimation of the "usefulness" of the reconstructed fingers.

RESULTS

No complications were observed postoperatively, and estimations of the functional results were almost satisfactory.

CONCLUSION

This procedure significantly improved the prognosis of the replantation of severely crushed digits.

Posttraumatic thumb reconstruction

LEARNING OBJECTIVES

After reading this article, the reader should be able to: 1. Discuss the critical anatomic features of the thumb as they affect on reconstructive decision making. 2. Define the goals of reconstruction. 3. Discuss an algorithm for thumb reconstruction according to the level of amputation. 4. Understand the role of prosthetics in thumb reconstruction.

BACKGROUND

The function of the thumb is critical to overall hand function. Uniquely endowed with anatomic features that allow circumduction and opposition, the thumb enables activities of pinch, grasp, and fine manipulation that are essential in daily life. Destruction of the thumb secondary to trauma represents a much more significant loss than would result from loss of any other digit. Therefore, significant effort has been focused on thumb reconstruction. Numerous techniques have been described, ranging from simple osteoplastic techniques to complex microsurgical procedures. With an appreciation of the unique anatomic properties of the thumb, the hand surgeon is better able to understand the goals of thumb reconstruction and to develop an algorithm for thumb reconstruction. With such an understanding, an individualized reconstructive plan can be developed for each patient.

METHODS

A great many options are available for posttraumatic thumb reconstruction. Optimal results are obtained by pursuing an organized and logical approach to reconstruction based upon the level of tissue loss. Reconstruction methods depend on the location of the amputation and range from homodigital and heterodigital flaps to partial-toe transfer or a great-toe wrap-around flap to first-web-space deepening using Z-plasties, a dorsal rotation flap, or a distant flap, to distraction osteogenesis, lengthening of the thumb ray, spare parts from another injured digit in the acute setting for pollicization or heterotopic replantation, and microvascular toe transfer.

RESULTS

Amputations in the distal third of the thumb are generally well-tolerated. The primary reconstructive issues are the restoration of a padded and sensate soft-tissue cover, as well as aesthetic considerations. First-web-space deepening will generally provide excellent results for amputations at the distal half of the middle third. In the proximal half of the middle third, lengthening of the thumb ray is generally required. Distraction lengthening of the first metacarpal is a useful and reliable technique that provides up to 3 cm of length without requiring complex microsurgical methods. Spare parts from another injured digit may be used in the acute setting for pollicization or heterotopic replantation. Microvascular toe transfer is an excellent option for elective reconstruction. However, other options also are available and may be more appropriate in some cases. Less ideal options include the various types of osteoplastic reconstruction.

CONCLUSIONS

The reconstruction of posttraumatic thumb defects is a challenging and rewarding surgical endeavor. The value of a functioning thumb is immense, and its reconstruction is worthy of considerable effort. Despite the elegant reconstructive options available, the best results are obtained with replantation or revascularization whenever possible. Finally, the treatment plan always must be derived from a careful assessment of each patient's posttraumatic function and specific reconstructive needs.

Rational Treatment for Multiple Digit Congenital Absence

A case is discussed in which a young male was born with symbrachydactyly of multiple digits in whom nonvascularized proximal toe phalanges were transferred to the aphalangic digits when he was an infant. This initial surgical procedure was later followed by webspace deepening and ultimately by distraction lengthening of the digits. At 8 years of age, he has a very functional hand with mobile metacarpophalangeal joints in all reconstructed fingers. In fact, he uses this reconstructed right hand as his dominant extremity. The case is discussed in context of phalangeal growth potential, specific indications for this type of reconstruction, and final long-term outcome. This case also helps to recommend rational treatment protocols for similar congenital hand anomalies.

Reconstruction of thumb loss complicated by skin defects in the thumb-index web space by combined transplantation of free tissues

OBJECTIVE

To introduce a new technique of 1-stage reconstruction for thumb loss complicated by thumb-index web space contracture and to report its clinical effectiveness.

METHODS

From November 1994 to September 2004 there were 11 patients with thumb loss and contracture in the thumb-index web space who had a combined transplantation of free tissues to reconstruct the missing thumb and to rebuild the web space. The reconstructive procedure used the second toe and the anterolateral thigh flap in 5 patients, the second toe and the scapular flap in 2, the big toe wraparound flap and the anterolateral thigh flap in 3, and the big toe wrapround flap and the scapular flap in 1. The 2 independent free tissues were connected together by a vascular combination to form an assembly with 1 common vascular pedicle, which then was anastomosed to the selected vessels in the recipient hand. In this vascular series the dorsalis pedis artery and the greater saphenous vein served as the common vascular pedicle of the flap transfers and the radial artery and the cephalic vein provided the recipient vessels. The outcomes of the reconstructions were evaluated using the Michigan Hand Outcomes Questionnaire.

RESULTS

The flaps survived completely in all patients except 1. In this patient a small area in the distal part of the transplanted anterolateral thigh flap became necrotic but healed after dressing changes without the need for further surgical intervention. A mean follow-up period of 3.6 years showed a mean increase of 4.3 cm in the width of the thumb-index web space and a considerable improvement in overall hand function was noted on the Michigan Hand Outcomes Questionnaire with effect sizes of greater than 3 (large effect) in all domains.

CONCLUSIONS

Combined transplantation of the second toe or the big toe wraparound flap and a free skin flap is suitable to reconstruct a missing thumb and repair the associated skin defect in the adjacent thumb-index web space. We found good functional recovery and an acceptable appearance in this series of patients. Type of study/level of evidence: Therapeutic, Level IV.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic, Level IV.

Treatment of Painful Neuroma of Amputated Phalanx with Distal Toe Transfer: A Case Report

A painful neuroma in the amputation stump of a finger can be psychologically and physically disabling. Numerous surgical procedures have been attempted to prevent and treat amputation neuromas of the finger, but the results are inconsistent. Microsurgical transfer of the distal second toe to the amputated stump of the finger can provide a pathway and target for the regenerating axons and avoid recurrence of neuromas. In this article, we present the experience of successful treatment of amputation neuromas of an index finger with microsurgical distal toe transfer.

Symmetry of vascular pedicle anatomy in the first web space of the foot related to toe harvest: clinical observations in 85 simultaneous bilateral second-toe transfer patients

BACKGROUND

Toe-to-hand transfer is an accepted procedure for reconstruction of thumbs and fingers. Although the vascular anatomy of the toe has been well studied, its symmetry on both feet has not previously been reported.

METHODS

A retrospective review of 85 cases of simultaneous bilateral toe-to-hand transfers, performed between 1984 and 2002, was carried out. All of the pedicles were dissected in a retrograde fashion.

RESULTS

A symmetric vascular pedicle anatomy was found in 78.8 percent of the patients, whereas 21.2 percent of the patients had an asymmetric vascular pattern.

CONCLUSIONS

This result cautions surgeons about the possibility of vascular pedicle asymmetry between two feet in bilateral toe harvest. It proves once more the advantage of a retrograde pedicle dissection technique, which allows for a safe and straightforward toe harvest regardless of the vascular pedicle course variations.

[Decorative repair and reconstruction of subtotal thumb and finger defect with trimmed toe flap transfer]

OBJECTIVE

In partial loss of distal finger segment, a corresponding part of the toe tissue compound is harvested and transplanted for repair or reconstruction. This new procedure gives forth a new concept and is called decorative repair or reconstruction.

METHODS

In a series of 77 patients with 88 thumb and/or finger subtotal defects in forms of lateral half, dorsal half or volar half composite tissue defects were reconstructed with lateral nail-skin flap, dorsal skin-nail flap or pulp flap taken from corresponding part of the toes. The blood circulations were re-established by anastomosing digital arteries of the toe transplants and fingers.

RESULTS

In this series 75 patients with 78 fingers reconstructed are successful. The overall survival rate is 97.5%. Follow-up examinations made half to 12 years postoperatively showed the fingers are having a normal length, outward appearance and function. There are nails preserved. The pulps are full. Sweating function are present. Two-point-discrimination tests are between 4-6 mm.

CONCLUSION

By decorative reconstruction of subtotal dorsal, lateral, or volar halves defect of thumb and/or fingers by transplanting corresponding part of soft tissue taken from the toe has the merit of repair of any parts of tissue loss precisely what is needed. This procedure is better than any traditional toe-to-hand transfer and realizing the exact meaning of decorative reconstruction.

Cortical Plasticity Following Upper Extremity Injury and Reconstruction

Today's view of the adult central nervous system is that of an adaptive and responsive system. Plastic surgeons, because of the motor and sensory reconstructions they perform, need to have an understanding of brain plasticity following upper extremity injury, reconstruction, and rehabilitation. Functional MRI and transcranial magnetic stimulation can identify cortical plasticity in humans. For instance, these techniques have identified changes in excitability and body site representation in the motor cortex in patients following motor reconstruction and motor relearning. Therefore, cortical plasticity and its manipulation may be an important contributor to functional outcome following reconstruction. In the future, cortical plasticity may have implications for reconstruction and rehabilitation.

The use of the reverse radial fasciosubcutaneous flap to provide soft tissue coverage and a distal recipient artery in a difficult case of toe-to-thumb transfer

Traumatic amputation of the thumb is a devastating injury. Toe-to-hand [Wei FC, Chen HC, Chuang CC, Chen HT. Microsurgical thumb reconstruction with toe transfer: selection of various techniques. Plast Reconstr Surg 1992;93:345; Wei FC, Tarek AE. Toe-to-hand transfer: current concepts, techniques and research. Clin Plast Surg 1996;23:103] transfer is a sophisticated option for replacing this vital structure, but this challenging procedure, is even more demanding if recipient vessels are difficult to locate, inadequate or even absent. Another frequently encountered difficulty in cases of traumatic thumb amputation is inadequate soft tissue cover in the region of the amputation stump or the first web space. Often this defect or potential defect requires a preliminary tissue transfer procedure, before toe-to-hand transfer can be considered.

[Combined tissue transplantation for complicated hand injury]

OBJECTIVE

To investigate the effect of combined types in treating cases with 2 to 5 tissues transplantation.

METHODS

305 cases treated from December 1989 to December 2002 were analyzed and summarized. 214 cases were constructed with 2 combined tissues transplantation, the combined types were:toe combined flap,the second toe at both sides transplanted, 2 flaps combined transferred; 75 cases were constructed with 3 combined tissues transplantation, the combined types were: the second toe at both sides combined flap, 2 flaps combined toe, 3 flaps combined transferred; 11 cases were constructed with 4 combined tissues transplantation, the combined types were: 2 flaps combined 2 toes,1 toes combined 3 flaps, 4 flaps combined transferred; 5 cases were constructed with 5 combined tissues transplantation, the combined type was: the wrap flap and the second toe with 1 vascular pedicle and another second toe combined bilateral femoris anterior flaps were transferred. The principles of repair were: the thumb was reconstructed first,the wrap round flap was used for the thumb's skin, the second toe transplantation was used for the thumb defect. The opposite toe was transferred to finger to reconstruct the pinch function. 1 or 2 flaps were selected for repair according to the area of damage. The anterolateral thigh flaps were used for the large areas and the lateral arm flaps were used for the small areas in selecting the donor area.

RESULTS

Of the 722 tissues in 305 cases, 14 of them were necrosis, in which the toe were 6 and the flap were 8,and other transferred tissues all survived, the survival rate of tissue transplantation was 98.1%. 251 cases were followed up for 1 year to 7 years (2. 6 years in average). All the patients could care themselves in daily life. The pinch and opposition functions of the constructed thumbs and fingers were recovered, the two-point discrimination was 6 to 14 mm, but 2 cases recovered adduction function only because the thumb was 6 degree defect without the thenar muscle and did not fix the reconstructed thumb in opposite side in operation. All transplanted flaps recovered protecting sensory with S2, 56 flaps required plastic operation because of their swelling appearance. The donor areas gained primary stage heal in 285 cases, 20 cases gained secondary stage heal, in which part grafted skin necrosis in donor of wrap round flap were 12 cases, the distal of donor big toe necrosis were 2 cases and grafted skin necrosis in donor of anterolateral thigh flap were 8 cases and skin grafted were successful.

CONCLUSION

Different combined types can be used according to the traumatic situation. Surgical operation and early rehabilitation is conducive to the final function. Combined tissue transplantation is the best way to repair complicated hand injuries.

[Bilateral three-toe transplantation with dorsalis pedis flap and first web space flap for damage injury in the hands]

OBJECTIVE

To discuss the surgical method and effect of repair of damage injury in the hands.

METHODS

Of the 29 cases, 22 were males, 7 were females. Their ages ranged from 15 to 31. The size of defect areas ranged from 18 cm x 8 cm to 22 cm x 10 cm. Along with dorsalis pedis flap, lateral hemi-pulp flap was taken from great toe and first web space flap. The second toe was taken from one foot to reconstruct the thumb, second and third toe from another foot was used to reconstruct two fingers. The dorsalis pedis flaps were used to cover palm and dorsum of hand. The lateral hemi-pulp flaps from great toe and first web space flaps were used to reconstruct first web space of hand. RESULTS With the 58 combined flaps, 29 thumbs and 58 fingers were reconstructed. Follow-ups was done for 1 to 8 years. All the thumbs and fingers of 29 hands were reconstructed. Their shape and function were well recovered.

CONCLUSION

This new surgical method is effective in preserving the function of injured hand. The function of the injured hands can be preserved by this surgical method, therefore this method is optimal.

Salvage of free second toe with venous thrombosis by shunting retrograde arterial flow of second dorsal metatarsal artery

Although there are case reports about salvaging amputated digits without venous return by shunting retrograde blood flow from a distal digital artery to a proximal vein (Smith et al., Plast Reconstr Surg 71:52, 1983), successful salvage of a congested free toe with efferent arteriovenous (AV) shunting retrograde arterial flow from the second dorsal metatarsal artery (SDMA) has never been reported. In this paper, we describe the possible factors for venous thrombosis, the errors we committed in the operation, and how the free toe can survive without venous drainage.

Continuous brachial plexus blockade for digital replantations and toe-to-hand transfers

Microsurgical operations of the hand are common procedures of reconstructive surgeons. Sympathetic blockade of the vessels provides increased blood flow to the injured extremity, which increases the success rate of the surgery. Moreover, postoperative pain management can be performed with continuous blockade of the nerves. In this article, the effect of continuous brachial plexus blockade on patients who underwent upper extremity microsurgical operation was evaluated.A total of 16 patients were operated on either for replantation or for toe-to-hand transfer. The first group (n = 9) received combined continuous brachial plexus blockade and general anesthesia, and postoperative pain management was performed with continuous brachial plexus blockade. The remaining 7 patients operated on general anesthesia and conventional pain management. All transplant and replants were followed by use of Doppler flowmeter. Pain was scored by visual analog scale every 4 hours postoperatively. Continuous brachial plexus blockade was found to be effective in both sympathetic blockade and postoperative pain management. Continuous brachial plexus blockade must be considered when microvascular anastomosis is performed at the upper extremity, especially at the digital vessels, which are very susceptible to vasospasm.

Isolated third-toe transfer: indications, technique, and reliability

BACKGROUND

Isolated third-toe transfer is a versatile and safe technique when indicated.

METHODS

Between January of 1984 and January of 2003, 37 isolated third-toe transfers were performed in 31 patients.

RESULTS

Only one partial loss was noted among 37 transfers. There were 24 male and seven female patients, with an average age of 27.4 years (range, 7 to 43 years). Twenty-five patients received additional toe transfers. Secondary surgery was performed in 17 toes of 15 patients to improve the functional and cosmetic results. Patients were followed for 2 to 180 months (average, 36 months) and no significant donor-site morbidity was seen.

CONCLUSIONS

Basically, the indications for isolated third-toe transfer are evaluated in two groups. Third-toe transfer is absolutely indicated when it is necessary for restoring basic hand functions in multiple-finger amputations. It is indicated because both second toes are transferred or the remaining second toe is adjacent to the previously transferred great toe. The other absolute indication is the unavailability of second toes because of trauma or deformity. Third-toe transfer is indicated relatively if it is used for additional reconstruction when basic hand functions are regained or already exist. Another relative indication is its better size match for proposed reconstruction. Second and third dorsal and plantar metatarsal arteries can be used as the pedicle artery for third toe-transfer; however, if second-toe transfer has already been performed or is planned, the third plantar or dorsal metatarsal artery should be used. Isolated third-toe transfer is a useful and reliable technique, especially in multiple-finger amputation reconstruction.

Simultaneous Double Second Toe Transfer for Reconstruction of Adjacent Fingers

BACKGROUND

The authors reviewed their results with simultaneous double second toe transfer for reconstruction of adjacent fingers.

METHODS

From January of 1984 to January of 2003, simultaneous double second toe transfer was performed for reconstruction of adjacent fingers in 140 patients (48 before wound closure, 92 after). Functional thumbs were present in all of them. There were 104 male and 36 female patients, with an average age of 29.1 years (range, 2 to 57 years). Index and middle fingers were reconstructed in 90 patients, middle and ring fingers in 49 patients, and ring and little fingers in one patient. The average operation time was 11 hours 25 minutes, which was much shorter than double the average time of a single second toe transfer (8 hours 31 minutes; double time, 17 hours 2 minutes). Twenty-six toes were reexplored for vascular insufficiency and three of them were lost. Secondary surgery was performed in 98 patients to improve function and cosmesis.

RESULTS

Patients were followed up at an average period of 47.5 months (range, 2 to 210 months). Forty-two patients had complete functional evaluation at a minimum 2-year follow-up. The mean active range of motion of the reconstructed finger joints in these patients was 69.4 degrees for metacarpophalangeal joints, 31.1 degrees for proximal interphalangeal joints, and 8.2 degrees for distal interphalangeal joints. Two-point discrimination was between 3 and 13 mm (average, 7.5 mm). All donor sites were closed primarily and no obvious donor-site morbidity was noted, except for one hallux valgus deformity that was corrected by surgery.

CONCLUSIONS

The functional and aesthetic results of double second toe transfers for adjacent two-finger reconstruction are superior to those of a single second toe-to-single finger reconstruction in multiple-finger amputations. Double second toe transfer performed simultaneously reduces the cost and total time of the operation, enables faster rehabilitation, and hastens patient adaptation.

The aesthetic mini wrap-around technique for thumb reconstruction

In the past 12 years, 16 thumb defects at, or distal to, the interphalangeal joint were reconstructed using a great toe mini wrap-around flap. A flap including the entire nail and most of the distal phalanx of the great toe was used. Fifteen of the grafts survived. The sensory recovery of the reconstructed thumb was good as assessed by 2-point discrimination test with an average of 10 mm (range 5-15), and there were no complaints of cold intolerance. This technique results in good cosmetic appearance, and all patients were pleased with the cosmetic aspect of the thumb and there was no significant morbidity at the great toe donor site. The final decision to reconstruct a distal thumb amputation is influenced by gender, job, and age of the patients. The great toe mini wrap-around flap is an excellent reconstruction technique in selected patients.

Successful reconstruction of the ring finger using a twisted toe flap

There have been many case reports of thumb reconstruction using wraparound flaps, toe-to-thumb transfer, and twisted toe flaps but, to the authors' knowledge, there have been no previous reports of reconstruction of total ring finger deficit. In this report, they present a case of successful reconstruction of the ring finger amputated proximal to the proximal-interphalangeal joint, using a twisted toe flap and simultaneous application of a free groin flap to the donor site. Use of the modified twisted toe flap is suggested to be a cosmetically useful method for reconstruction of the ring finger.

Painful foot neuromas after toe-to-thumb transfer

Reconstruction of the thumb by transfer of a toe has evolved technically to the point that this complex procedure can result in a mobile, sensate, and aesthetically pleasing digit that contributes to an almost-normally functioning hand. Donor site deformity is well recognized, primarily as it relates to the appearance of the foot after transfer of the hallux to the thumb position and stiffness of the remaining portions of the big toe. The present report describes donor site disability related to painful neuromas of the superficial and deep peroneal nerves and the common plantar digital nerve to the first webspace. Salvage of the disabled donor foot is possible by applying techniques used to treat painful neuromas of the upper extremity, neuroma resection, and muscle implantation. The specific techniques used in treating this painful foot donor site after toe-to-thumb transfer are described.

Overcoming soft-tissue deficiency in toe-to-hand transfer using a dorsalis pedis fasciosubcutaneous toe free flap: Surgical technique

Reconstruction of combined finger and soft-tissue defects poses a technical surgical challenge. We present our experience with a hybrid flap: the dorsalis pedis fasciosubcutaneous-toe free flap. In a single stage, this flap solves the problem of medium-sized defects associated with digit losses in the hand. Donor-site morbidity has been minimal.

Immunohistochemical study of skin nerve regeneration after toe-to-finger transplantation: correlations with clinical, quantitative sensory, and electrophysiological evaluations

Cutaneous nerve regeneration following toe-to-finger transplantation was studied by immunohistochemical technique using antibody to protein gene product 9.5 (PGP 9.5) which is a specific neuronal marker. By this technique, epidermal and dermal nerves were semi-quantified and the Meissner's corpuscles were quantified. There were also quantitative sensory tests (QST) including pinprick, pressure and temperature, as well as electrophysiological studies including digital nerve sensory conduction, digital nerve somatosensory evoked potentials and sympathetic skin response at the pulp of the transplanted toes. The opposite corresponding normal finger and normal toe served as controls. Study subjects were 20 adult patients with toe-to-finger transplantation for at least one year. A score system was used to quantify the results of histochemical, psychophysiological and electrophysiological studies. Clinically 7 patients had good recovery and 13 patients had poor recovery. Cutaneous nerve regeneration in the transplanted toes was incomplete with epidermal nerve, dermal nerve and the Meissner's corpuscle significantly reduced. The nerve regeneration was correlated with clinical recovery, QST and electrophysiological data. These findings indicate that immunohischemical technique is useful to evaluate skin nerve regeneration following toe-to-finger transplantation, and that although nerve regeneration did occur, it was incomplete and correlated with the severity of hand injury.

Resurfacing of the donor defect with a second toe plantar flag flap after free first toe pulp flap

A second toe plantar flap was attached to the donor site after a free first toe pulp flap. Twenty-two days postoperatively, the wound had almost healed. Although the whole defect is impossible to cover with this flap, partial resurfacing will reduce the healing time and morbidity from recurrent ulceration.