Toe transplantation for isolated index finger amputations distal to the proximal interphalangeal joint

Recent Advances in Immediate Toe-to-Hand Transfer

Toe-to-hand transfer is the last option for definitive reconstruction of the hand when digits have been lost as a result of traumatic amputations, congenital anomalies, or tumor ablation. Immediate toe-to-hand transfer for the treatment of acute hand injuries is defined as an emergency operation performed when replantation is impossible or failed. The aim of this article is to propose the indications, advantages and disadvantages of immediate toe to hand transfer as well as to compare the overall results with elective cases.

The Indications for Toe Transfer after “Minor” Finger Injuries

Toe-to-hand transfer is widely considered to be unjustified for “minor” finger injuries. In this invited personal view article the indications for toe-to-hand transfer for finger amputation and neurocutaneous and major pulp defects are discussed, and a classification of multidigital injury that has both prognostic and decision-making value is presented. In the author's opinion a toe transfer should always be considered as an option when reconstructing “minor” finger injuries, as it can reproduce significant long-term benefit to the hand and the patient's sense of well being. The procedure should be carried out in the acute period, not only because it is technically easier and better for hand function, but above all because the surgeon can save structures that will be lost if the transfer is delayed.

Multiple toe transfer and sensory free flap use after a traumatic amputation of multiple digits. Surgery done in a single setting: a case study

Crush avulsion injuries to the hand with concomitant traumatic amputation of multiple digits can be a devastating injury to the patient. These injuries have multiple issues occurring under emergency conditions. When feasible, replantation of the multiple digits is optimal, but in many cases, it is not possible. Because of the crushing force on the digits, they are not viable candidates for replantation. The usual course of treatment for these patients is a two stage procedure, usually involving a groin flap. Here, we present the case of a patient who had a left hand skin avulsion of the whole palm and P1 of index, long, ring and small fingers. The left index finger had a complete amputation at the P2 level, the long, ring and small fingers all had complete amputations at the P1 level. This injury was dealt with by a left foot second and third toe transplant, a sensory free flap from the left big toe and a fourth toe microvascular free transfer to the left hand. The remainder of the defect was managed with a 10 × 14 cm reversed radial forearm flap and a combination of full and split thickness skin grafts. The procedure was performed in a single operation, obviating the need for a second surgery. This procedure optimized the patient's outcome during a single setting, making it an ideal choice in an emergency setting.

Reconstruction of the distal finger with partial second toe transfers by means of an exteriorised pedicle

This study reports the outcome of a series of ten microsurgical fingertip reconstructions with partial toe transfers in which the vascular pedicle was exteriorised and subsequently excised after the transfer had become established. The aim of this technique was to provide better aesthetic and functional outcomes. The technique was successful and without complication in nine of the ten patients who had excellent functional and aesthetic outcomes. Arterial thrombosis resulted in partial necrosis of the fingertip in the other case.

Microvascular free on-top plasty in multidigital amputations

Bidigital amputations proximal to the PIP joints severely impair function and cosmesis of the hand. The author presents a clinical series of five patients in which a three-fingered hand was reconstructed through microvascular transfer of one of the stumps on top of the other. Five male patients with amputation of two fingers proximal to the PIP joint were treated surgically. One of the stumps was transferred as a local free composite flap on top of the other stump. All five transfers were successful. The mean operative time was 2 h 15 min. The subjective improvement on hand function and cosmesis, as evaluated by the patients, was positive. Free microvascular on-top plasty is a straightforward and reliable procedure for improving cosmesis and function in hands with two fingers amputated proximal to the PIP joint, without additional donor morbidity outside the already injured hand.

Severe mutilating injuries to the hand: guidelines for organizing the chaos

Major hand injuries have become a rarity in Western countries. The fact that there are well trained teams devoted to their management, should not obscure the fact that the first emergency surgeon has the major role of setting the foundations for a reconstruction. Understanding the goal to be sought: the 'acceptable hand' (one with three fingers, with near normal length, near normal sensation and a functioning thumb), is hoped to be of great help in primary care. Preservation of vital structures such as joints, flexor tendons, and vessels, in the initial debridement, which will help to build this 'acceptable hand' are discussed. The general guidelines for management of finger amputation and soft tissue problems are also given.

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.

Immediate Toe-to-Hand Transfer in Acute Hand Injuries: Overall Results, Compared with Results for Elective Cases

In the past 5 years, 25 mutilated digits were reconstructed with immediate toe-to-hand transfers after acute hand injuries, for 21 patients. The overall results of the immediate toe-to-hand transfers were evaluated and compared with the results of 65 elective procedures performed during the same period by the same surgeon. There were 15 cases of great toe-to-hand transfer for thumb reconstruction, two cases of second toe transfer for index finger reconstruction, and four cases of simultaneous two-toe transfer for reconstruction of multiple-digit amputations. Two cases (two of 25 cases, 8 percent) were successfully salvaged with emergency reexploration. The incidences of emergency reexploration and postoperative infection were not significantly different from those for elective toe-to-hand transfer cases. The duration of industrial insurance coverage was much shorter than for elective cases, averaging 225 days (p < 0.001). Approximately 44 percent of the patients maintained their original jobs after immediate toe-to-hand transfer. The subjective satisfaction self-assessment scores of aesthetic appearance and function for the newly reconstructed thumb averaged 80 and 88 (of a total score of 100), respectively. Although satisfaction was lower than for elective reconstruction (p < 0.001), it was higher than for reconstruction of other digits. The donor-site appearance after great toe harvesting was mostly unsatisfactory. Immediate toe-to-hand transfer provides many advantages over the elective procedure in acute hand injuries, including single-stage reconstruction, shortened convalescence, early return to work, and socioeconomic efficiency. Because there were no significant differences in the success rates, frequencies of complications, or ultimate functional results, immediate toe-to-hand transfer is a safe and reliable procedure that is indicated for specific cases of acute digital amputation.

Minimizing impairment in laborers with finger losses distal to the proximal interphalangeal joint by second toe transfer

Traditionally, toe-to-hand transfers have been reserved for thumb amputations or for use after severe mutilating injuries. The authors report their experience with the use of second toe-for-finger amputations with preserved or reconstructible proximal interphalangeal joints in manual workers. The aim of the procedure was to reduce impairment and to upgrade the hand from a functional and cosmetic standpoint. Fifteen second-toe wrap-around or variations were carried out on 11 adults (18 to 41 years old). Four patients with two or more finger amputations received two sequential second toes; four patients with two finger amputations received one toe; and each of three patients with single-digit amputation received a single toe. All but one amputation were performed less than 3 weeks after the accident. All toes survived. Range of motion at the native proximal interphalangeal joint was more than 90 percent in all patients but one; however, it was minimal at the transplanted joints. Patient satisfaction was high from a cosmetic and functional standpoint. Ten of 11 laborers resumed their previous activity. On the basis of this experience, a classification with aesthetic and functional implications is proposed to help in the decision-making process when dealing with multidigital injuries. It is concluded that second-toe transfer is an excellent choice for finger amputation distal to the proximal interphalangeal joint in laborers. Its prime indication is for amputations of two fingers where at least one toe should be transferred, as required, to achieve an "acceptable hand" (three-fingered hand). Early transfer allows salvage of critical structures from the damaged finger, such as joints, tendons, and bone, that otherwise would be lost. Early transplantation is highly recommended.