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

Long-term Follow-up of Hand-degloving Injury Treated by Conventional Methods

Despite medical advances, degloving injury remains one of the most difficult traumatic injuries to treat. The conventional method for treating degloving injury of the hand is reconstruction with a groin flap. However, few reports have described the mid- or long-term functional and aesthetic outcomes after a hand reconstruction with a groin flap. This case report describes a 68-year-old woman with no specific medical history who presented with a severe degloving injury of the right hand, caused by a roller machine. The area of skin loss was covered with a pedicled groin flap that was separated after 3 weeks. Five years after the reconstruction, she had poor functional and aesthetic outcomes. The Japanese Society for Surgery of the Hand version of the Quick Disabilities of the Arm, Shoulder and Hand score was 57.5; the Hand20 score was 60; and the Michigan Hand Outcomes Questionnaire score was 37.5. The static two-point discrimination of the index and middle fingers was more than 15 mm, and Semmes-Weinstein monofilament examination showed that the sensation thresholds of these fingers were purple and blue. The range of motion was 10-degree angle of extension and 60-degree angle of flexion for the metacarpophalangeal joints of the index and middle fingers. Grip strength was 0.0 kg; pulp pinch strength of the index and middle fingers was 1.1 and 0.8 kg, respectively; and side pinch of the index and middle fingers was 0.1 and 0.7 kg, respectively.

A comparative study of thumb reconstruction through the transplant of the first toe compound free flap between emergency surgery and elective surgery

This study compared emergency surgery with elective surgery for thumb reconstruction to explore the advantages, safety, and clinical value of emergency reconstruction. By comparing the advantages and disadvantages of thumb reconstruction in emergency surgery and elective surgery, it provides data support for optimizing the treatment process and methods. In this study, 22 patients who underwent thumb reconstruction in Rizhao people's Hospital from January 2018 to December 2020 were randomly divided into emergency operation group and elective operation group. The differences in operation period, hospitalization time, postoperative complications, hand function score, and satisfaction score between the 2 groups were analyzed. The operation period and hospitalization time of patients in the emergency surgery group were significantly lower than those in the elective surgery group, with statistical significance (P < .05). There was no significant difference in postoperative complications between the 2 groups (P > .05). After 3 months of rehabilitation training, the 2-point discrimination, functional score, and satisfaction score of the reconstructed thumb in the emergency surgery group were higher than those in the elective surgery group, and the difference was statistically significant (P < .05). Emergency reconstruction of the thumb can reduce operation time and hospitalization time, reduce operation costs, and obtain a more ideal appearance and function.

Reconstructive Principles for the Metacarpal Hand: Case Report

Metacarpal hand is one of the most devastating upper-extremity lesions. We report a case of a multidigit amputation corresponding to a Wei et al.5 IA metacarpal hand in a 56 year-old-male. He underwent a sequential toe-to-hand transfer to the third and fourth radii. Reconstruction of the metacarpal hand, either in an acute or deferred presentation, must consider some reconstructive principles, including the identification of the structures to be spared and the coverage strategies for the acute stage. Toe-to-hand transfer is the preferred technique when replantation is not an option. It is critical to know which structures should be transferred to which positions, as well as to adapt the reconstructive plan to the characteristics from each patient.

Reconstruction of mutilating hand injuries by microsurgical free tissue transfers from the foot

INTRODUCTION

The aim of this study is to present various hand reconstruction methods and provide technical notes regarding the treatment of mutilating hand injuries using free-tissue transfers from the foot and to investigate whether these transfers provide patients with a usable hand or not.

PATIENTS AND METHODS

Ninety patients with mutilating hand injuries were included in the study. A total of 101 procedures were performed. Patients were contacted by phone to evaluate their working status and to record any complaints regarding their donor sites. The Quickdash questionnaire was conducted for the 53 patients who could be reached. Operative techniques, secondary procedures, finger survival, and physiotherapy data were noted retrospectively.

RESULTS

In 36 patients, a trimmed great toe was transferred to the thumb. Second toe-to-thumb transfers were performed in 8 patients, and second toe-to-finger transfers were performed in 10 patients. In 13 patients, 2 toes from one side were transferred, and in 6 patients, 3 toes were transferred to the hand. Bilateral toe transfers were performed in 9 patients. Eight patients underwent joint transfers, of which 2 involved joint transfers from both feet. The overall finger survival rate for the transfer procedures was 95.04%. The average Quickdash score of the patients who could be reached (n = 53) was 27.49, with 62.3% of the patients being able to use their hands in their previous jobs, and 26.4% needing to change their jobs because of their hand injuries. 41.5% of the patients had no donor site complaints. 47.2% had mild complaints, and 11.3% had major donor site complaints.

CONCLUSION

Multiple-toe transfer techniques along with flap coverage options should be considered, and delicate planning is mandatory to achieve at least a basic or acceptable hand. Three toes, including the great toe, can be transferred in a single operation by dissecting both the dorsal and plantar arterial systems. Crush injuries of the dorsal side of the hand may be reconstructed using combined transfers of bones, joints, extensor tendons, and skin. In our series, 88.7% of patients with mutilating hand injuries were able to return to work after we performed tissue transfers from the foot.

Measurement properties of the Michigan hand outcomes questionnaire: Rasch analysis of responses from a traumatic hand injury population

PURPOSE

This study aimed to use Rasch analysis to test the content, scoring, and measurement properties of the Michigan Hand Outcomes Questionnaire (MHQ).

METHODS

MHQ scores from 196 patients with hand and wrist conditions were collected in an outpatient hand rehabilitation facility. Rasch analysis was conducted to assess the fit statistics of MHQ to confirm the scaling structure of disability subscales, and to identify differential item functioning.

RESULTS

The MHQ did not fit with the Rasch model (χ² = 2376.78, df = 74, p < 0.001), and most thresholds of item responses were disordered. The original scoring algorithm derived from 5-point Likert response options was adjusted to 3-point Likert (10 items) and 4-point Likert (11 items) based on the visual inspection of the thresholds map. Differential item functioning was present in the revised scale based on the age, sex, and dominant hand. Only 3 revised subscales of the MHQ including activities daily living (one hand), aesthetics, and satisfaction showed acceptable fit to the Rasch model. Unidimensionality was achieved in all revised subscales.

CONCLUSIONS

The overall MHQ had a substantial misfit from the Rasch model. Despite efforts of item reduction and rescoring, we did not reach a satisfactory solution. This calls into question the validity of the statistical evaluations performed on this scale using the traditional scoring.Implications for rehabilitationThe MHQ was designed to measure different dimensions of pain and disability but demonstrates multiple measurement problems that undermine it use in present form.It is not appropriate to sum all 37 items of the MHQ into a single score.Three subscales of activities daily living (one hand), aesthetics, and satisfaction can provide unidimensional subscales scores with interval level scaling if scored with our proposed Rasch-based revised scoring.The 27-item version of the MHQ is shown to have strong psychometric properties for administration with patients with hand injuries; however, it requires further validation.

Emergency toe-to-hand transfer for post-traumatic finger reconstruction: A multicenter case series

BACKGROUND

The aim of this paper was to evaluate the outcomes of a homogenous series of emergency with a toe-to-hand transfer reconstructions with a different timing: immediate (same surgical step with the debridement), primary (in the first 24 h), early (24-72 h after the debridement) or delayed (72 h-7 days).

MATERIALS AND METHODS

Between 2001 and 2011, 31 patients received an immediate reconstruction with a toe-to-hand transfer. Data on indications, timing, type of surgery, complications and outcomes (sensory and motor recovery, patient satisfaction) were extrapolated and recorded.

RESULTS

Most of the procedures in our series (71%) were performed in the first 24 h. Survival rate was 100%. The only complications were 3 venous thrombosis (10%), solved with surgical re-exploration. Only 1 patient required secondary surgery for web deepening. No functional problems were recorded at the donor site. Sensibility recovery was acceptable in all patients; toe mobility was higher for the reconstructed thumb (85%) than for other digits (77%). Patient satisfaction was high with regard to functional results and lower but acceptable with regard to the aesthetic outcome. There was no difference in satisfaction rate of patients treated within 24 h or within 7 days.

CONCLUSION

No conclusive evidence exists in favor of an immediate versus a primary, early or delayed emergency reconstruction. Emergency toe transfer for finger reconstruction is a safe procedure and its outcomes are comparable to those reported in the literature for secondary reconstruction. Immediate reconstruction has the advantage of an easier dissection, but early or delayed reconstruction gives more time to discuss with the patient and to plan surgery.

A flap based on the plantar digital artery arch branch to improve appearance of reconstructed fingers: Anatomical and clinical application

AIM

To investigate blood supply features of the flap based on the plantar digital artery arch and arch branch artery, and the treatment of outcomes of reconstructed fingers by the plantar digital artery arch branch island flap.

METHODS

Eight fresh foot specimens were employed with red emulsion infusion and microdissection. The vascular organization was observed in the second toe, such as initiation site, the course, and the number of the plantar digital artery arch branch. There were 15 fingers of 13 patients (8 males and 5 females) with finger defects accompanied by toe transfer, using the plantar digital artery arch branch flap inserted in the neck of the second toe to correct the appearance defect caused by a narrow "neck" and a bulbous tip.

RESULTS

The intact plantar digital arches were identified in all specimens. The plantar digital artery arch had 5 branches. The range of external diameter of the arch branch was 0.4-0.6 mm. All the plantar digital artery arch branch island flaps and the reconstructed fingers survived. These cases were conducted with a follow-up period for 3-18 months (average, 9 months). All the plantar digital artery arch branch island flaps and reconstructed fingers demonstrated a satisfactory appearance and favorable sense function. The reconstructed finger-tip characteristic was good, with no obvious scar hyperplasia. The range of flexion and extension of reconstructed fingers was favorable as well.

CONCLUSIONS

The plantar digital artery arch and arch branch artery possess regular vasa vasorum and abundant vascularity. A flap based on the plantar digital artery arch branch is an ideal selection for plastic surgery of reconstructed fingers.

Microsurgical thumb repair and reconstruction

In this article, we review microsurgical reconstructive techniques available to treat thumb amputation at different levels based on our experience. We reference techniques used by other surgeons and identify the most suitable technique for different clinical situations. Indications and techniques for microsurgical partial or composite transfer of the great or second toe for thumb reconstruction are summarized. Different microsurgical transfer techniques suggest a great freedom of surgical choices. However, the choices are considerably restricted if all functional and cosmetic requirements are to be met. We recommend individualized surgical design and reconstruction because each case of thumb amputation is unique.

Functional salvage of a hand after unsuccessfull attempt of replantation

Amputation by crush injuries generally represents a contraindication for replantation, and especially when the lesion is caused by the summation of multiple concomitant traumatic mechanisms.

We present the case of a 22 year- old female who arrived in our service with a crush/torsion amputation of all long fingers at the metacarpo-phalangeal level of the right hand. After the unsuccessful attempt of replantation, the functional reconstruction of the hand was achieved by using a double free flap transfer: anterolateral thigh perforator flap (ALT) and digital block transfer of second and third toes.

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.

Neo-digit functional reconstruction of mutilating hand injury using transplantation of multiple composite tissue flaps

PURPOSE

Functional reconstruction of mutilating hand injuries poses a challenge to the surgeon. We present our experience with use of multiple composite tissue flaps transplant for functional reconstruction of hand in patients with mutilating hand injuries. The associated merits and demerits of these surgical approaches are briefly discussed.

METHODS

From August 2004 to October 2014, functional reconstruction of hand with transplantation of multiple composite tissue flaps was performed in 8 patients. These included the toe with dorsal pedis artery flap, the reverse posterior interosseous artery flap, and the anterolateral thigh flap. Mean interval from injury to functional reconstruction was 10.6 days.

RESULTS

All transplanted skin flaps and reconstructed neofingers survived completely. Only 1 patient developed wound infection at the recipient site (hand), which resolved without any debridement or revision surgery. At the donor site (foot), partial skin necrosis was observed in 1 patient, which healed with local wound care. In other patients, all wounds healed without any complications. The average range of movement at the neofinger metacarpophalangeal and interphalangeal joints was 38° and 73°, respectively. None of the patients required revision surgery.

CONCLUSION

Use of negative pressure wound therapy and multiple composite tissue flap transplantation appears to be an effective strategy for hand functional reconstruction in patients with mutilating hand injuries. Among the multiple composite tissue flaps, use of toe transplantation combined with reverse posterior interosseous artery flap appears to be the best option.

One-stage cosmetic finger reconstruction using a second toe island flap containing terminal branches of the toe artery

INTRODUCTION

A finger reconstructed by toe transfer may have morphological defects. We report the results of second toe transfer for 1-stage finger reconstruction with an island flap based on terminal branches of the toe artery.

HYPOTHESIS

The technique can improve the morphological outcomes of reconstructed fingers.

MATERIALS AND METHOD

Between January 2008 and June 2011, toe-to-finger transfer was performed for 36 fingers in 31 patients. An island flap containing terminal branches of the toe artery was embedded in the neck of the second toe to eliminate the morphological defect caused by stenosis in that area.

RESULTS

All reconstructed fingers and all flaps survived. No donor site complications occurred. The mean follow-up was 8 months (range, 5 to 25 months). The morphology of the reconstructed finger was close to that of a normal finger, and a natural transition could be observed in the finger pulp, the finger neck, and the junction between the toe and the finger. Sensory recovery of the finger pulp ranged from S1 to S3+. The mean pinch strength of the reconstructed fingers was 48% to 60% of that of the contralateral side. The mean DASH scores were 52.9, 48.9, and 46.0 for patients that had the index, third, and fourth fingers reconstructed, respectively, and the lowest mean aesthetic score was 70.

DISCUSSION

The method provides good aesthetic and functional outcomes, and overcomes aesthetic difficulties associated with other methods of toe transfer for finger reconstruction.

Immediate Great Toe Transfer for Thumb Reconstruction After Tumor Resection: Report of 3 Cases

BACKGROUND

Modern oncologic surgery aims not only to obtain tumor-free margins but also to spare or reconstruct limb function and preserve quality of life. A negative tumor margin in the digit generally requires amputation; therefore, function is preserved with reconstruction. We report results of simultaneous ablative tumor resection and reconstruction with a great toe transfer in patients requiring surgery for aggressive benign and malignant thumb tumors.

METHODS

Between 2000 and 2009, three patients with extensive soft tissue tumors of the distal thumb underwent amputation to obtain wide negative surgical margins. In each case, an immediate trimmed toe-to-thumb transfer was performed. Results, evaluated retrospectively, included a review of perioperative complications, donor-site morbidity, oncologic status, objective functional outcomes, and subjective patient satisfaction.

RESULTS

Three patients were found with either locally aggressive benign (n = 1) or malignant (n = 2) tumors of the thumb. All patients underwent immediate reconstruction after amputation through the base of the proximal phalanx for tumor eradication. No perioperative complications were encountered, and all toes survived. Full thumb opposition and protective sensation were achieved in all patients. All patients returned to their previous occupation without functional limitations. There is no local or distant tumor recurrence. Delayed wound healing at the ipsilateral foot donor site occurred in all 3 patients. Wet-to-dry dressing changes were successful in 2 patients, whereas the third patient required full-thickness skin grafting. All patients were satisfied with their reconstruction.

CONCLUSIONS

An immediate great toe-to-thumb transfer should be considered when thumb amputation is required to satisfy adequate oncologic margins. Such a transfer provides simultaneous restoration of digit length, position, sensation, and acceptable esthetics. This procedure is technically demanding and requires an experienced microsurgical team as well as appropriate patient counseling and consent before surgery.

Risk factors for reexploration in toe-to-hand transfer: a multivariate analysis of 363 cases

BACKGROUND

Reexploration after toe-to-hand transfer increases the risk of failure. In this study, the authors aimed to identify risk factors for reexploration after toe-to-hand transfer.

METHODS

The medical records of 363 patients who underwent single toe-to-hand transfer between 2000 and 2010 were reviewed retrospectively. Patient demographics, clinical data, and operative data were collected, and multivariate analysis was performed.

RESULTS

Of these 363 patients, 299 toes (82.4 percent) had primary success in transplantation. Sixty-four toes required reexploration, of which seven toes failed. The overall success rate was 98.1 percent. Of the 64 toes that required reexploration, arterial spasm was found in 39 (60.9 percent), arterial thrombosis was found in 27 (42.2 percent), and venous thrombosis was found in 16 (25.0 percent). Multivariate logistic regression analysis revealed that postoperative wound infection, metacarpal hand injuries, and preceding flap coverage were independently associated with reexploration.

CONCLUSIONS

Reducing reexploration in toe-to-hand transfer may be facilitated by managing or avoiding these risk factors. Particular attention must be paid to avoid postoperative wound infection, which was the single greatest factor contributing to reexploration (adjusted OR, 12.6).

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Multiple-digit resurfacing using a thin latissimus dorsi perforator flap

Traumatic digit defects of high complexity and with inadequate local tissue represent challenging surgical problems. Recently, perforator flaps have been proposed for reconstructing large defects of the hand because of their thinness and pliability and minimal donor site morbidity. Here, we illustrate the use of thin latissimus dorsi perforator flaps for resurfacing multiple defects of distal digits. We describe the cases of seven patients with large defects, including digits, circumferential defects and multiple-digit defects, who underwent reconstruction with thin latissimus dorsi perforator flaps between January 2008 and March 2012. Single-digit resurfacing procedures were excluded. The mean age was 56.3 years and the mean flap size was 160.4 cm(2). All the flaps survived completely. Two patients had minor complications including partial flap loss and scar contracture. The mean follow-up period was 11.7 months. The ideal flap for digit resurfacing should be thin and amenable to moulding, have a long pedicle for microanastomosis and have minimal donor site morbidity. Thin flaps can be harvested by excluding the deep adipose layer, and their high pliability enables resurfacing without multiple debulking procedures. The latissimus dorsi perforator flap may be the best flap for reconstructing complex defects of the digits, such as large, multiple-digit or circumferential defects, which require complete wrapping of volar and dorsal surfaces.

Bilateral microvascular second toe transfer for bilateral post-traumatic thumb amputation

In bilateral thumb amputations, the functional impairment is serious and every attempt should be made to reconstruct the thumb. We report a case of bilateral post traumatic thumb amputation, reconstructed with bilateral second toe transfer. Only two such cases have been reported in literature so far. Though there are various modalities for the reconstruction of thumb, microvascular toe transfer has its own merits. The convalescent period is minimal with excellent function. It is bilaterally symmetric and aesthetically superior to the osteoplastic reconstruction. The technical details are discussed, and the long term functional and aesthetic results are presented.

A systematic review of outcomes of toe-to-thumb transfers for isolated traumatic thumb amputation

BACKGROUND

Toe-to-thumb transfer is an established procedure for reconstruction of traumatic thumb amputations. The four types of toe-to-thumb transfers are the second toe, the great toe, the wrap-around great toe and the trimmed great toe transfers. The purpose of this study is to conduct a systematic review of the literature to compare outcomes amongst different methods of toe-to-thumb transfers.

METHODS

A literature search using 'toe-to-thumb transfer' combined with 'thumb injury' and 'thumb reconstruction' as keywords and limited to humans and the English language identified 633 studies. Studies were included in the review if they: (1) present primary data, (2) report three or more toe-to-thumb transfers for isolated complete traumatic thumb amputation between the metacarpophalangeal joint and the interphalangeal joint (both excluded) and (3) present functional outcome data.

RESULTS

Twenty-five studies representing 450 toe-to-thumb transfers met the inclusion criteria. They included 101 second toe transfers, 196 great toe transfers, 122 wrap-around transfers and 31 trimmed toe transfers. The mean survival rate was 96.4%. No statistically significant differences could be detected between the four transfers with regards to survival, arc of motion, total active motion, grip and pinch strength and static two-point discrimination.

CONCLUSIONS

All four types of toe transfer procedures have predictably high survival rates and good patient satisfaction scores. The current data are inadequate to make any comments with regards to donor site morbidity. Till such data are available, an evidence-based recommendation for the superiority of a specific type of toe-to-thumb transfer cannot be made.

Recurrent calcifying aponeurotic fibroma of the thumb: case report

We present an unusual case report of an aggressive, recurrent calcifying aponeurotic fibroma of the thumb in an adult man with invasion into the distal and proximal phalanges, the skin, the radial and ulnar neurovascular bundles, and the tendons, treated with amputation and an immediate toe-to-thumb transfer.

Thumb reconstruction with toe transfer

Microsurgical toe transfer has become a gold standard option for amputated thumb reconstruction. It can be used to correct almost any thumb defect. However, for optimal functional and esthetic results, proper initial care, preoperative planning, proper selection of suitable techniques, adjunct or secondary procedures and proper, postoperative rehabilitation are important.

Functional and aesthetic results of immediate reconstruction of traumatic thumb defects by toe-to-thumb transplantation

Traumatic thumb defects significantly affect the function and appearance of the hand; thus, thumb reconstruction is very important in clinical practice. In our report, three reconstruction strategies of toe-to-thumb transplantation, based on the amputation level of the thumb, were used for immediate thumb reconstruction in 27 patients with traumatic thumb defects. All procedures were performed successfully. Patients were satisfied with the function and appearance of the reconstructed thumb. These results indicate that if the reconstruction method is properly selected based on the amputation level of the thumb, toe-to-thumb transplantation is feasible for the immediate reconstruction of the thumb.

Immediate reconstruction of a nonreplantable thumb amputation by great toe transfer

BACKGROUND

When replantation of an avulsed/amputated thumb is not feasible, toe-to-hand transfer may be considered as a reconstructive option in appropriately chosen patients. Although selection criteria are purposefully restrictive, immediate one-stage transfer, as opposed to a delayed procedure, provides many advantages. Primary reconstruction reduces hospitalization and operative and recovery time. It also may expedite return of function and allow patients to return to work sooner. The ability of the patient to undergo extensive microvascular reconstruction at the time of injury, the psychological preparation required, and the need to understand potential risks are important factors to consider.

METHODS

In the past 5 years, six patients suffering thumb amputation underwent immediate great toe-to-hand transfer. The overall results of these thumb reconstructions were evaluated retrospectively with regard to function, outcome, length of stay, complications (e.g., infection, contracture, reexploration), and time to return to work/normal activity. The authors calculated objective and subjective scores with which to quantify patient satisfaction and clinical success.

RESULTS

All of the authors' patients were laborers who suffered work-related avulsion-amputations. No complications were reported during initial hospitalization, lasting an average of 12 days. Donor-site morbidity was minimal.

CONCLUSIONS

The data suggest that thumb reconstruction using great toe transfer can be safely and reliably performed during the initial presentation in selected patients. The economic and therapeutic advantages should be weighed against the risks associated with this approach when evaluating thumb avulsion-amputations.

Great toe-to-thumb microvascular transplantation

Great toe to thumb transplantation offers the ideal reconstruction because it replaces the absent thumb with nearly identical anatomy. Functional donor site morbidity is minimal as compared with the aesthetic one; however, in comparison to the hand, the functional and aesthetic gain is tremendous. Anatomic and operative details are discussed along with preoperative and postoperative management. Postoperative functional evaluation of the thumb and donor site is assessed. Forty years of experience with this composite tissue transplantation has proven its status as the gold standard for thumb reconstruction.

Great toe-to-thumb microvascular transplantation after traumatic amputation

The thumb is a vital part of the hand. After traumatic loss of the thumb, hand function diminishes considerably. The loss of the great toe, on the other hand, although unsightly, is not a considerable functional loss to the foot. Aesthetic and functional losses are restored to the hand following great toe transplantation to the thumb position, with very little functional loss to the foot. Anatomic and operative details are discussed, along with preoperative and postoperative management. Postoperative functional evaluations of the thumb and donor site are assessed. Forty years of experience with this composite tissue transplantation has proven that great toe-to-thumb microvascular transplantation is the gold standard for thumb reconstruction after traumatic amputation.

Posttraumatic finger reconstruction with microsurgical transplantation of toes

This article outlines current methods of toe transplantation as applied to posttraumatic finger reconstruction (excluding the thumb). Key points that are important during the initial assessment and surgical treatment of such injuries are addressed. Reconstructive options for distal and proximal finger injuries, single and multiple finger injuries, and metacarpal hand injuries are presented, and the timing of toe transplantation procedures is discussed. Finally, additional concepts and techniques that, with experience, have proved useful for optimizing functional and esthetic results are highlighted, along with schemes for motor and sensory rehabilitation.

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.

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.