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Purpose: Modified heterodigital neurovascular island flaps and free lateral great toe flaps are dependable methods for treating thumb-tip defects with phalangeal bone exposure. We retrospectively analyzed and compared the details and results of the two methods., Methods: This retrospective study included 25 patients with thumb injuries with phalangeal bone exposure treated between 2018 and 2021. Patients were categorized as per the following surgical methods: (1) modified heterodigital neurovascular island flap (12 patients, finger flap group) and (2) free lateral great toe flap (13 patients, toe flap group). The Michigan Hand Outcome Questionnaire, aesthetic appearance, Vancouver Scar Scale, Cold Intolerance Severity Score, static 2-point discrimination, Semmes-Weinstein monofilament, and range of motion of the metacarpophalangeal joint of the injured thumb were evaluated and compared. In addition, operation time, hospital stay, return-to-work time, and complications were recorded and compared., Results: In both groups, the defect was successfully repaired, with no cases of complete necrosis. The 2 groups had similar mean scores in static 2-point discrimination, Semmes-Weinstein monofilament, range of motion, and Michigan Hand Outcome Questionnaire scores. The aesthetic appearance, scarring, and cold tolerance of the toe flap group were better than the finger flap group. The operation time, hospital stay, and return-to-work time in the finger flap group were shorter than the toe flap group. The finger flap group had 2 complications-a superficial infection and 1 case of partial flap necrosis. The toe flap group had 3 complications-a superficial infection, 1 case each of partial flap necrosis, and partial skin graft loss., Conclusion: Both treatments can achieve satisfactory results; however, they each have advantages and disadvantages., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2024 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: Data objectively comparing outcomes following pollicization versus toe-to-thumb transfer for reconstruction after traumatic thumb amputation in adults remains sparse. Given that this decision is reliant on personal preference, it is important to understand the subjective nature of these preferences, particularly in the context of culture. The purpose of this study was to compare Eastern and Western societal and hand surgeon preferences for pollicization versus toe-to-thumb transfer for traumatic thumb reconstruction., Methods: Investigators from 6 international locations recruited local hand surgeons and members of the general population. Austria, Germany, the United States, and Spain were grouped as "Western" nations. China and India separately represented "Eastern" nations. Participants completed a questionnaire evaluating their personal preferences for pollicization and toe-to-thumb transfer. The questions posed to the general population and hand surgeons were identical. Demographic data were also collected., Results: When comparing the Western nations, China, and India, there was no difference in personal preferences within the general population for pollicization versus toe-to-thumb transfer. In contrast, most Indian hand surgeons favored toe-to-thumb transfer and most Western surgeons were uncertain about which procedure they would favor. Surgeons had more optimistic expectations regarding postoperative hand function, new thumb sensation, and hand appearance following pollicization than the general population. Similarly, for toe-to-thumb transfer, a greater proportion of surgeons predicted good-to-excellent function, sensation, and appearance., Conclusions: There was no clear, observed "East" versus "West" difference in the general population's personal preferences for pollicization versus toe-to-thumb transfer among study participants. The members of the general population and hand surgeons had different outcome expectations., Clinical Relevance: Understanding how culture influences patient and hand surgeon preferences for pollicization versus toe-to-thumb transfer may help guide future decision-making for traumatic thumb reconstruction., (Copyright © 2024 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Hemi-hamate arthroplasty is a method used to reconstruct complex fracture-dislocations of the proximal interphalangeal joint of the fingers. Other graft sites, including the toe second and third phalanges, have been proposed as alternatives to hemi-hamate arthroplasty due to variable clinical outcomes and anatomy. Through a prospective magnetic resonance imaging (MRI)-based study in asymptomatic individuals, we aimed to characterize the anatomy of the proximal interphalangeal joint and compare this with the hamate, second and third toes to determine the closest anatomical match using pre-determined measurements. Our results show that the second and third toes have greater anatomical similarity to the proximal interphalangeal joint of the fingers compared to the hamate. High-resolution MRI is a reliable method of characterizing the anatomy of these structures and could be a useful clinical tool in determining reconstructive options in the management of this challenging injury. Level of evidence: II., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

We report the application and results of skin defect coverage using the free lateral great toe flap in revision surgery for residual postoperative deformities in Wassel-Flatt type IV-D thumb duplications. This retrospective study included five patients treated between June 2020 and September 2021 to correct angular deformity and repair the secondary skin defect. All the flaps survived. The patients were followed up for 8-12 months and all the reconstructed thumbs had a satisfactory appearance. The results of the Japanese Society for Surgery of the Hand scoring system were excellent in one patient, good in three patients and fair in one patient. The results of the Alignment, Ulnar and Radial stability, Range of motion and Aesthetical aspects (ALURRA) scoring system were good in four patients and moderate in one patient. Level of evidence: IV., Competing Interests: Declaration of conflicting interestsThe authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

This study evaluates the long-term donor site outcomes after second toe transfers for congenital hand differences performed during childhood. In total, 25 toe transfers in 18 patients were followed up for a mean period of 17.4 years. We examined the patients clinically, radiologically and with a gait analysis system. Patient-reported outcome measures were collected. The patients were asymptomatic and there were no problematic clinical or radiological findings. Patients expressed high levels of satisfaction. The results were consistent, regardless of the resection level in the toe transfer or whether the operation was unilateral or bilateral. No postoperative complications or late reoperations on the foot were observed. Level of evidence IV., Competing Interests: Declaration of conflicting interestsThe authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

A 37-year old male patient with a right-hand firework injury. An extreme hand reconstruction was performed. The second and third rays were sacrificed enlarging the first space. The diaphysis of the second metacarpal bone became a tubular graft to reconstruct the fourth metacarpal. The thumb consisted only in the first metacarpal bone. The result was satisfactory, according to the wishes and needs of the patient, a three-finger hand with an opposable thumb, obtained in only one surgical treatment and without using free flaps. The concept of an "acceptable hand" is related to the surgeon's and patient's opinions.

Background: Reverse-flow posterior interosseous artery (rPIA) flap is an excellent tool for restoration of defects in the hand and upper extremity, sparing the main arteries to the hand. Its reliability has been well established., Materials and Methods: Fifty-one cases of rPIA flap involving 49 patients were retrospectively reviewed. The inclusion criteria were age, sex, etiology, size and location of the defect, flap size, number of perforators included, pedicle length, flap inset, donor site coverage, complications, and ancillary procedures., Results: This study included 44 men and 5 women, ranging in age between 10 and 73 years. The subjects had soft tissue defects of the hand and upper extremity mainly due to traumatic injuries, including scar contractures of the first web space in 18 cases, thumb amputations in 6 cases, and congenital defects in 1 case. Among the 51 rPIA flap elevations, 3 cases involved flap failure due to the absence of proper pedicle. A fasciocutaneous pattern was observed in 45 cases and a myocutaneous pattern in 3 cases. In 5 cases of unplantable thumb amputations, the rPIA flap was performed for arterial inflow to the secondary toe-to-thumb transfer. Venous congestion of varying degrees was noted in 7 cases involving partial necrosis in 2 cases. During the mean 17 months of follow-up, patients were generally satisfied with the final outcomes., Conclusion: The rPIA flap can be used not only for soft tissue coverage of the hand and upper extremity but also as a recipient arterial pedicle for a secondary toe-to thumb transfer.

Background: Toe transfer to hand is a viable option for patients, which can provide functionally useful digits. Harvesting of the second toe is still accepted as a demanding surgical procedure. The major questions before this transfer are the location and the dominance of the arterial anatomy of the second toe. The authors present the incidence of patients with a dominant plantar artery system and a description of a versatile technique that can be used for toe transfers in these patients., Methods: The study was designed retrospectively. Toe to hand transfers performed between 2010 and 2018 were reviewed. The patients with a dominant plantar arterial system were included in this study. The dorsalis pedis arterial graft technique described by the authors was used in all cases with a dominant plantar system. All of transfers were done by the senior author. All cases followed up at least one year post-operatively. The survival of the transferred finger was examined in the follow-ups., Results: Eleven toe to hand transplantation cases in nine traumatic patients were included in this series. The reason for the operation was trauma in all patients. Second toe transfer was performed in all of the cases. Plantar dominant arterial system was seen in 3 of the 9 patients. Dorsal arterial system was dominant in the remaining six patients. Dorsalis pedis arterial graft technique was used in these four cases. All of the toes survived, and reexploration was needed in 2 cases because of venous insufficiency. Mean follow-up time was 16.4 months., Discussion: This is the first study to recommend the use of dorsalis pedis as an arterial graft instead of vein grafts. This surgical method described will make these rarely performed transfers easier and affect the success rates positively.

Purpose: To evaluate the clinical utility of surgical reconstruction of finger pulp defects using a plantar flap derived from the toes, with vascular anastomosis of the toe-finger artery and the plantar-palmar vein of the finger., Methods: Between April 2018 and November 2020, 29 patients with finger pulp defects underwent treatment via the transplantation of pulp tissue from the second toe, with the plantar vein of the toe and the palmar vein of the finger being anastomosed during this procedure. In addition, an anastomosis of the toe and finger artery and nerve was conducted, with a flap size of 1.0 cm * 0.8 cm-2.3 cm * 4.0 cm being used for such repair. Donor tissue sites were closed without introducing deformities or other complications., Results: In all patients in the present study, flap tissues survived and did not exhibit evidence of vascular crisis over a mean 16.8-month follow-up period (range 8-24 months). After successful skin flap grafting, they exhibited good elasticity and a soft texture. At three months post-surgery, some patients reported partial recovery of touch sensation in the transplanted tissue, while pain recovery was evident in some patients at 4-6 months post-surgery. No deformities or other complications were observed at the donor site, and the ability of patients to walk normally was not impaired., Conclusion: The anastomosis of toe plantar flaps with the palmar vein can facilitate the repair of finger pulp injuries without the need to dissect the dorsal vein of the toe, allowing for the suturing of donor tissue sites without causing any deformities or other complications. This surgical approach can easily be conducted with satisfactory clinical outcomes., (© 2022. The Author(s).)

Claw nail deformity is common in patients with fingertip injury. The optimal reconstruction remains unclear. We devised a unique strategy for reconstruction of claw nail deformity. We divided the approach into three parts: soft tissue reconstruction, bone graft and nail bed graft. In the soft-tissue reconstruction, a reverse digital arterial finger flap for the finger or an extended palmar flap advancement with V-Y plasty for the thumb was selected. A part of the distal phalanx of the second toe including periosteum was harvested as a bone graft. A nail bed graft from the big toe was performed. We reconstructed in 11 cases of claw nail deformity using our strategy. All cases achieved significant improvement with no recurrence of the claw nail deformity. Moreover, there was no donor site morbidity.

Background: Reconstruction for proximal thumb amputation at the carpometacarpal (CMC) joint level is extremely challenging. All thenar muscles are lost and other fingers might be lost or injured. Transmetatarsal trimmed great toe (TGT) transfer may be an option in such cases., Methods: Between 2012 and 2018, 11 patients who had amputation of the thumb at the CMC joint level were reconstructed by transmetatarsal TGT transfer in a single stage. There were seven cases in which the right hand was affected and four cases in which the left hand was affected. Three cases involved a contracture scar at the thumb stump and required web space reconstruction. Average follow-up was 33.9 months (range: 12-76 months) RESULTS: All toe transfers survived. The average of static two-point discrimination (S2PD) was 14.6 mm; the average scores of the Quick Disabilities of the Arm, Shoulder, and Hand (quickDASH) questionnaire and the Michigan Hand Outcomes Questionnaire (MHQ) were 18.6 and 73.8, respectively. Two cases did not achieve opposition due to mispositioning of the neothumb. In nine cases achieving opposition, the Kapandji score ranged from 4 to 9, pinch ranged from 3 to 11 lbs, and grip ranged from 15 to 86 lbs. In the donor foot, three patients had neuroma and two had a new callus on the palmar side of the second and third metatarsal heads. The average foot and ankle disability index score was 91.6., Conclusion: Single-staged transmetatarsal TGT transfer is safe and useful for thumb reconstruction at the CMC joint level. This reconstructive method is suitable for manual workers, especially in the developing countries., Competing Interests: Declaration of Competing Interest None declared., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Traumatic thumb amputations can seriously jeopardise hand function. Several alternatives for reconstructing an opposable thumb have been described, including distraction osteogenesis, index finger pollicisation and free toe transfer. We present in this article the case of a young male patient that sustained a circular saw injury to his non-dominant thumb which resulted in loss of his distal phalanx. Preserving the sensate pulp allowed later reconstruction with an on-top free second toe transfer achieving a satisfactory outcome., (Copyright © 2020 SFCM. Published by Elsevier Masson SAS. All rights reserved.)

Background: Microsurgical toe-to-hand transfer is a gold standard when it comes to repairing a thumb defect. Great toenail flap, thumbnail valva flap, free great toe, and second toe transplantation are the common methods in thumb reconstruction. Second toe transplantation achieves good function, but poor esthetics. Great toe transplantation achieves better esthetics, but hindered walking, due to the foot's loss of the great toe and moreover suboptimal thumb function. It is difficult to maintain both functional and esthetic satisfaction in thumb reconstruction., Methods: We experimented with three different methods of toe to hand transfer. From October 2009 to July 2019, 30 patients with traumatic thumb defects received one of 3 different kinds of thumb reconstruction in our clinic according to their level of amputation. Divided evenly into three groups of ten, group one received a great toe transplantation, group two received a second toe transplantation, and group three received a combined great toenail flap and second toe phalanx transplantation. Each of the patients' thumbs had different levels of amputation at the metatarsophalangeal joint (MPJ) or distal interphalangeal joint (DIPJ)., Results: One patient suffered from a partial flap necrosis and received a groin flap to cover the defect. No other thumbs had any complications. The functional and esthetic results of both the donor and the recipient sites were satisfactory. Results show that, for patients with traumatic thumb defects, the combined transfer of flap and second toe phalanx was the best option., Conclusions: Compared to the great toe or second toe transfer, combined free transfer of the great toenail flap and second toe phalanx achieved a substantially better functional and esthetic result in the thumb reconstruction.

Congenital thumb hypoplasia is a rare deformity of the upper extremity. The classification of thumb hypoplasia was created by Blauth in 1967 (types I to V). The base of the first metacarpal bone is absent for hypoplasia types IIIb to V, therefore, toe-to-hand transplantation is not recommended. A stable first carpometacarpal joint has been considered a mandatory factor for a successful toe-to-hand transplantation. The aim of this study is to describe a new technique for thumb reconstruction with the second toe transfer and metatarsophalangeal joint (MTPJ) arthrodesis, which can provide a five-digit hand and restore thumb functionality for thumb hypoplasia IIIb to V. We performed second toe-to-hand transplantation with MTPJ arthrodesis for 3 pediatric patients (mean age, 69 mo) with congenital thumb hypoplasia IIIb (n=2), grade V (n=1). Long-term follow-up evaluated the functions and esthetics of the hands for grade IIIb patients (n=2). We believe the second toe transfer with MTPJ arthrodesis transplantation is a promising method for reconstructing a full-length congenital or traumatic thumb absence for the pediatric population.

It was found that conventional toe graft alone could not meet the patients' needs for wound repair, so we hypothesized that it would be more effective to treat thumb and finger defect by toe graft with dorsalis foot flap. This prospective study was conducted in 104 thumb defect patients to investigate the clinical effect of thumb reconstruction using toe graft with dorsal foot flap for the treatment of thumb defects. These patients were randomly divided into the dorsal foot group and the control group by randomized double-blind method, with 52 patients in each group. The second toe was used for thumb reconstruction transplant in both the groups. After thumb reconstruction, the abdominal pedicled flap was used to repair the surgical wound in the control group whereas the dorsal foot flap was used to repair the surgical wound in the dorsal foot group. Three months after surgery, the efficacy of surgical treatment, evaluation of two-point discrimination, postoperative complications, function of reconstructed thumb, operation time, and hospitalization time were recorded and compared between the two groups. MHOQ questionnaire was used to evaluate and compare the patients' satisfaction with finger reconstruction in both the groups. The surgical therapeutic effect, the function of the reconstructed thumb, and satisfaction with finger reconstruction were significantly higher in the dorsal foot group compared to the control group (all p < 0.05). The postoperative two-point discrimination, postoperative complication rate, operation time, and hospitalization time of patients in the dorsal foot group were significantly lower compared to the control group (all p < 0.05). Thumb finger reconstruction using the second toe transplant with dorsal foot flap had a beneficial effect on thumb defect patients. It can effectively improve finger function and sensory recovery of patients while reducing complications., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: After loss of a thumb, the big toe is a possible donor site for reconstruction with wrap-around free flap and trimmed-toe transfer techniques. Early reconstructions seem to reduce the risk of post-operative infections, despite several studies that show different infection rates of the recipient site in immediate toe-to-hand transfer. The authors carried out a retrospective analysis of their experience in thumb reconstruction with big toe transfer and evaluated the results achieved with both immediate and delayed reconstructions in terms of infection occurrence., Patients and Methods: From 2000 to 2017, patients who presented cut, crush and avulsion injuries in the thumb were selected and 33 toe-to-thumb transfers were performed. Patients were divided into two groups: in group A, patients underwent immediate reconstruction, while in group B delayed reconstructions were performed. The two groups received identical antimicrobial prophylaxis. Reliability of the immediate or delayed reconstruction was compared in terms of flap survival, requirement for a secondary intention healing and, in particular, rate of infection., Results: 29 male and 4 female patients were treated. Toe-to-thumb transfers were performed in both groups: in group A, 8 wrap-around free flaps and 4 trimmed toe transfers; in group B, 11 wrap-around and 10 trimmed toe transfers. No flap loss occurred in either groups. No cases of infection were detected in the transferred toes., Conclusion: For toe-to-thumb transfer, there are published reports of a wide range of infection rates of the recipient sites. The authors compared their results in terms of infection rate between immediate reconstruction, group A, and delayed reconstruction, group B. Immediate toe-to-thumb transfer showed equal success rates to delayed transfer. No statistically significant difference in risk of infection between the two groups was found. Results showed that the immediate reconstruction was as safe and reliable as the delayed one., Competing Interests: The authors declare that they have no conflict of interest., (© Georg Thieme Verlag KG Stuttgart · New York.)

Traumatic digit amputation generates functional, aesthetic and psychological disabilities. Such post-traumatic consequences call for a rigorous therapeutic approach, aiming at an early secondary surgical procedure - which is ideally to be performed before the patients psychologically recover from their initial trauma. The therapeutic principle consists in improving the global function of the hand, basically aiming at re-creating a quality pollici-digital pinch, ideally thin, stable, sensitive, strong, mobile enough, but also, when possible, at improving the aesthetic aspect of the hand. The therapeutic arsenal includes not only surgical processes using local ressources in order to improve the allocation of the remaining digital capital such as phalangisation, elongating techniques, proximal amputation, digital translocation and redistribution but also remote processes - such as osteoplastic and toe-to-hand transfer techniques. The authors expose their approach and indications of secondary digit reconstruction procedures in mutilated hand. They conclude that a thorough knowledge and mastery of the vast available therapeutic arsenal, a fine and profound analysis of the benefits and downsides of each available surgical technique, a comprehensive acknowledgement of the patient's personal information such as age, gender, profession, dominant hand, status of the mutilated hand, physical and psychological health as well as patient's desire are all necessary in order to define the best therapeutic strategy for each particular case., (Copyright © 2019. Published by Elsevier Masson SAS.)

Ulnar hemimelia is a rare congenital deformity. The severity of the deformity increases with the number of fingers that are absent. Clearly, grip function is impossible with a mono-finger hand. Here, we present a case report of a patient with bilateral ulnar hemimelia that included the absence of radial fingers and also deformity in the toes of his left foot. A toe-to-hand transfer was performed successfully to help the patient gain grip function. Both the patient and the parents were very pleased with the result. To our knowledge, this is the first case report of a patient with ulnar hemimelia and absent radial fingers who was treated with a toe-to-hand transfer.The most important factors in a successful surgery are careful preoperative planning and microsurgical expertise. Angiography is the key to careful planning, and physiotherapy should also be done to increase the patient's functions. The psychological well-being of patients and parents will be positively affected after a successful surgery.

Background and Objectives: Congenital thumb hypoplasia is a rare deformity of upper extremity. The incidence for thumb hypoplasia grade II-V is 1:10,000 newborns per year in Latvia. A technique for extensor indicis proprius (EIP) tendon transfer with subperiosteal fixation was developed and used for thumb hypoplasia grades II and IIIa. Pollicization or second-toe-to-hand transplantation with metatarsophalangeal (MTP) joint arthrodesis was used for the reconstruction of hypoplasia grade IIIb-V. The aim of this retrospective cohort study is to evaluate the outcomes for reconstruction techniques used in one surgical center during a ten-year period by one surgeon to evaluate functional and aesthetical outcomes for new techniques., Materials and Methods: In total, 21 patients were operated on during 2007-2017, and 18 of these patients were involved in this study. Long-term follow-up was completed to evaluate the functions and aesthetics of the hands., Results: disabilities of the arm, shoulder and hand (DASH) was 9.35 (8-10.7) for the second-toe-to-hand with MTP joint arthrodesis transplantation method for pollicization method 19.8 (6-26.7), and for the EIP tendon transposition, 14.54 (0.9-56.3)., Conclusions: The postoperative functional parameters of congenital hand hypoplasia patients, regardless of the surgical method, are worse than the functional results of healthy patients . The use of the second-toe-to-hand with MTP joint arthrodesis transplantation method provides patients with congenital hand IIIb-V hypoplasia a stable and functional first finger formation. The functional results are comparable to the clinical results of the pollicization method while ensuring the creation of a five-digit hand., Competing Interests: The authors have declared no potential conflicts of interests regarding research, authorship, and/or publication of this article.

Background: Historically, complex amputations of the thumb have been managed in two stages and often require additional soft-tissue and tendon transfer for successful outcomes. This article provides several novel strategies to address these problems in a single stage using existing muscles, immediate free tissue transfer, and toe transfer., Methods: From a personal experience of 482 toe transfers, 24 cases were performed to reconstruct extreme thumb losses. All thumbs were reconstructed in one stage. In only one case, the thumb was reconstructed with a second toe transfer; the remainder had a great toe (or a part of it) used for reconstruction. Suture, advancement, or tendon transfers were performed in all to restore intrinsic muscle function. In 19 cases, the web needed to be resurfaced with free (n = 18) or local (n = 1) flaps., Results: All toes and flaps survived. Three patients required a secondary adductorplasty. Six of the seven patients with a metacarpal hand were able to perform tripod pinch. The rest had an average Kapandji opposition score of 7.5. Patients rated their functional and cosmetic result with a visual analogue scale score (ranging from 0 to 10) of 8.5 and 8.4, respectively., Conclusions: In proximal thumb amputations, the surgeon should pay attention not only to the obvious thumb loss but also to the first web and the thenar muscles. The author recommends abandoning the standard approach of a pedicled groin flap followed by a toe. Otherwise, the thenar muscles become useless, the first metacarpal contracts, and the need for tendon transfers skyrockets. Further studies are required to compare the outcomes of these results to those of more classic transfers., Clinical Question/level of Evidece: Therapeutic, IV.

The first toe-to-hand transplantation was done in 1898 by Nicoladoni. It was a staged procedure and the toe flap was based on a pedicle. With advancement of optical instruments and microsurgeons' skills in 1964 the first microvascular toe-to-hand transplantation on a rhesus monkey was done. The technique's development has not stopped, many authors have modified it to achieve better outcomes for both traumatic and congenital hand defects. The most commonly used toes for transplantation are first, second, and second to third toe block. Well described plantar and dorsal vascular systems for first web space vessels as well as possibility to perform successful perforator anastomosis allows us to improve toe-to-hand transplantation further. There is a paucity of studies on single fourth toe-to-hand transplantation. We performed fourth-toe transplantation for three pediatric patients (mean age, 73 mo) with congenital (n=2) and traumatic (n=1) hand defects. Common plantar digital arteries were used for blood supply to the transplanted toes. No vascular problems occurred, and all transplanted toes survived. Patients and parents are satisfied with functional and esthetic outcomes. Early podometry results show insignificant changes which should not harm the foot in the long-term. We believe the fourth-toe transplantation is a promising method to use to reconstruct congenital or traumatic absence of digits for pediatric population.

Purpose: Traumatic amputations of the thumb are rare in children compared with adults, but hand surgeons remain reticent to consider microsurgical reconstruction with toe-to-thumb transfers. This study reports the functional outcomes and complications of children with traumatic thumb amputations who underwent toe-to-thumb reconstruction., Methods: A retrospective review of children who sustained thumb amputations and whose parents elected for their child to undergo reconstruction by toe-to-thumb transfer was performed. Details of the level of thumb amputation, whether other fingers were also amputated, which toe was transferred on which vascular pedicle, survival of the transfer, and complications, were collected. Opposition, sensation, and growth of the toe-to-thumb transfers was measured. Functional and psychosocial outcomes were evaluated by both the parents and the older children using the Pediatric Outcomes Data Collection Instrument questionnaire., Results: Twenty-one thumb amputations in 19 children between the ages of 2 and 17 years were referred for secondary reconstruction. Ten were isolated thumb amputations and 11 were combined thumb and multiple finger amputations. Two children had bilateral thumb amputations. Twenty-one toe-to-thumb transfers were performed: 14 second toe transfers and 7 great toe transfers (3 great toe and 2 trimmed and 2 Morrison wraparound variations). There were no immediate postoperative reexplorations of the microsurgical anastomoses and all toe transfers survived completely. All children regained pinch and grasp function and sensation. There were no gait problems in the donor feet., Conclusions: Microsurgical toe-to-thumb transfers should be offered as an alternative option to the traditional techniques of distraction lengthening and pollicization, for posttraumatic thumb reconstruction in children for any level of amputation from just distal to the carpometacarpal joint to the interphalangeal joint. Toe-to-thumb transfer provides length, opposition, and sensation without disturbing ambulation and is associated with excellent psychosocial outcomes as evaluated by both parents and older children., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2019 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: Patient-reported outcome measures are an important metric in evaluating treatment efficacy of reconstructive surgery. Toe-to-hand transfer can restore vital prehensile function; however, this surgery is complex, extensive rehabilitation is required, and there are concerns about donor-site morbidity. This study longitudinally explores the benefits of this procedure, from the patient's perspective, using patient-reported outcome measures., Methods: Twenty-three patients who underwent free toe-to-hand transfers from 2012 to 2015 were evaluated preoperatively and postoperatively using the following validated questionnaires: the Michigan Hand Outcomes Questionnaire, the 36-Item Short-Form Health Survey, and the Lower Limb Outcomes Questionnaire. Subgroup analysis was performed between dominant and nondominant reconstructed hands., Results: Mechanism of injury was crush in 83 percent; the remainder sustained cutting, avulsion, and burn injuries. Thirty-four toes were transferred: nine great toes, 20 second toes, and five third toes. Michigan Hand Outcomes Questionnaire results showed significant improvement in overall activities of daily living, work, aesthetics, and patient satisfaction (p < 0.05). The results of the 36-Item Short-Form Health Survey showed significant improvements in physical and emotional roles (p < 0.05). The Lower Limb Outcomes Questionnaire showed no deterioration of foot function (p = 0.55). Subgroup analysis showed significant improvement in patient-reported outcome measures for patients undergoing dominant hand reconstruction but no difference between thumb reconstruction and finger-only reconstruction., Conclusions: Patient-reported outcome measures demonstrate the significant utility of toe-to-hand transfer procedures in both functional and psychosocial domains in that there are relatively greater benefits in reconstructing the dominant hand, and that donor-site morbidity is well tolerated., Clinical Question/level of Evidence: Therapeutic, IV.

Background: This article outlines our methods for thumb reconstruction following dorsal skin loss injury located between the metacarpophalangeal joint (MPj) and the entire nail affecting skin, nail, tendon, and bone in different combinations but with intact sensate palmar skin., Methods: Between 1990 and 2015, 24 patients were treated for dorsal thumb defects using 4 different surgical techniques. Five cases of dorsal compound traumatic loss were reconstructed by custom-made dorsal great toe transfer. Four patients with dorsal skin and nail loss located at the distal phalanx level were covered with the homodigital flap with reverse flow vascularization. In 9 patients presenting skin defects between the MPj and the nail, reconstruction was achieved by means of the kite flap. Six cases suffered extensive dorsal skin loss, and reconstruction was performed using different types of radial forearm flaps (cutaneous, tendineocutaneous, osteocutaneous, and fascial)., Results: Flap survival was obtained in all cases. No vascular complications occurred with free vascularized compound toe transfer., Conclusions: Reconstruction of dorsal thumb defects is imperative and its approach is strictly correlated to type of defect, patient's requests, and flap alternatives. For defects with nail involvement, the free osteo-onychocutaneous flap harvested from the great toe provides the best aesthetic result in selected young and well-motivated patients. An alternative is represented by the dorsoulnar flap, when the defect is located distally, or the fascial pedicle radial forearm flap, for major dorsal thumb defects, in patients refusing microsurgical reconstruction. The kite flap still represents a feasible solution for medium-size defects with an intact nail.

Objective: Toe-to-hand transplantation is a reliable procedure that replaces like-with-like in cases of a lost thumb or finger. The aim of this study is to investigate the effects of toe transplantation on patients from the perspectives of quality of life (QOL) and disability., Methods: Ten patients with traumatic amputation of a digit underwent reconstruction with toe transplantation. The mean age at injury was 40.2 years (range 17-59 years). Reconstructive options were 5 wrap-around flaps to 2 thumbs and 3 index fingers; 2 second-toe transplantations to 2 middle fingers, and 3 hemipulp-free flaps from the great toe to a thumb and an index finger. We hypothesized that toe transplantation would improve postoperative QOL and disability. Outcome assessments included completion of the SF-36, SAFE-Q, and DASH questionnaires before and after reconstruction. Scores on each test were calculated and intra-individual comparisons were made., Results: All scores for the eight SF-36 health domains improved, with a significant difference in Vitality from before to after surgery. In contrast, scores for all five SAFE-Q items worsened, with significant changes for the 'Pain and Pain-Related' and 'Physical Functioning and Daily Living' subscales. DASH scores improved after surgery in all cases., Conclusions: Our results suggest that toe-to-hand transplantation for amputated finger reconstruction is a good option in terms of improved QOL. However, worsened SAFE-Q scores imply that donor site problems could be expected and must be taken into account during surgical planning.

Vascularized toe joint transfers are used for proximal interphalangeal (PIP) or metacarpophalangeal reconstruction of the fingers in children or young adults, as an alternative to joint arthroplasty. In children, this reconstruction aims to restore range of motion (ROM) and the growing capacities. The typical donor sites are the PIP or metatarsophalangeal joints of the second toe. These transfers are performed with short vascular pedicles in order to simplify the surgical technique and reduce the overall morbidity. Local flaps and joint fusion are used to reconstruct the donor toe. Indications for these transfers are mainly compound defects due to trauma or infection. While these reconstructions provide a long-lasting result, the ROM achieved is always smaller than the normal ROM of the recipient joint., (Copyright © 2018 SFCM. Published by Elsevier Masson SAS. All rights reserved.)

Background:  After thumb amputations, restoration of function and aesthetic can be accomplished with microvascular free toe flaps. However, many patients in clinical practice do not choose this reconstruction despite positive reported outcomes. This study aims to determine patients' perceptions with respect to free toe flaps to improve areas of informed consent., Methods:  A retrospective survey was administered to patients with thumb amputations. Participants were required to complete a questionnaire about patient demographics, the Brief Michigan Hand Questionnaire (bMHQ), the standard gamble/time trade-off questionnaires for utility scores, and a questionnaire investigating potential reasons for electing not to undergo a free toe transfer., Results:  Thirty patients were enrolled in the study wherein 53% underwent a replantation procedure, 27% a revision amputation, and 20% a delayed reconstruction. Mean normalized score on the bMHQ was recorded as 63.54. Utility questionnaires yielded mean measures of 0.8967 and 0.86 on the standard gamble and time trade-off, respectively. From 14 elements, a majority (87%) stated flap failure as a major source of concern, followed by lack of understanding of risks and benefits (80%) and prolonged hospital stay (53%). Cultural/religious beliefs, aesthetic appearance of the foot, and concerns about footwear were not reported as important reasons in 90, 80, and 79% of patients, respectively., Conclusion:  A better understanding of patients' attitudes and beliefs with respect to free toe flaps will allow surgeons to better address their concerns during informed consent. This study emphasizes the importance to discuss about failure rates, risks, and benefits of the operation and prolonged hospital stay., Competing Interests: None., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

A few severe hand injuries represent a gray zone for the reconstructive surgeon, for which autologous tissue transfer and allotransplantation can yield satisfactory results, but not without downsides or morbidity.This article is written to address the dilemma of application of both techniques in those selected cases., Competing Interests: None., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Thumb amputation at the carpometacarpal level is very incapacitating. Pollicization may be considered. We describe an alternate technique for thumb reconstruction at the level of the metacarpal base using a trimmed great toe along with a vascularized second metatarsophalangeal joint, including the second metatarsal, all supplied on a single vascular pedicle. Two patients who had a combined soft tissue defect and amputation of the thumb close to the carpometacarpal joint were reconstructed with this method. A transposition of the second toe was performed on top of the remaining proximal phalanx of the great toe to decrease donor site morbidity. This technique provides adequate length to the thumb without compromising another finger by creating a new thumb using a double microsurgical toe transfer on a single vascular pedicle. We minimize donor site morbidity by transposing the second toe onto the great toe., (Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Microvascular toe interphalangeal joint transfer can serve as a means of autogenous digit proximal interphalangeal joint (PIPJ) arthroplasty. Among surgical options for treating dysfunctional, absent, or destroyed PIPJs, free toe joint transfer is the most technically challenging and carries the greatest donor site cost to patients. Despite drawbacks, free toe joint transfer is a valuable tool with considerable advantages over conventional arthroplasty in the appropriate clinical setting. Particular advantages include lifelong durability, coronal plane stability, low infection risk, and growth potential in skeletally immature patients. This technique requires a balanced assessment of the risk-to-benefit ratio for each patient., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Macrodactyly is an uncommon congenital hand condition that can be difficult to treat and that can have a profound negative impact on patients and their families. Although many treatments have been described, results tend to be inconsistent. The authors report a case in which a combination of ray resection, partial finger resection, and toe transfer resulted in a 4-digit hand with acceptable function and cosmesis., (Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

For painful, dysfunctional, posttraumatic metacarpophalangeal (MCP) joints, the free vascularized toe joint transfer may represent a good solution. Successful reconstruction is potentially limited, however, by 2 features of the traditional vascularized metatarsophalangeal (MTP) transfer: inadequate arc of flexion and insufficient soft tissue coverage. The solution to both of these dilemmas lies in the manner of utilizing the donor site. Because of its innate hyperextensibility, rotating the MTP 180° volar to dorsal provides the greatest arc of flexion in the reconstructed MCP. Excellent soft tissue coverage can be provided by elevating the skin paddle of the transferred second toe as a chimeric fillet flap, based on the tibial plantar digital artery., (Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

The metacarpal-like hand is a severe hand injury, never addressed before. It describes a hand that has lost a significant degree of prehension through a wide array of amputations, involving all digits proximal to the functional length except in one finger or in two digits, including the thumb. The thumb condition can be used to differentiate between two types. In type I, the thumb is intact or amputated at or distal to the interphalangeal joint (functional length); therefore, the reconstruction is focused mainly on fingers. In type II, the thumb is amputated proximal to the interphalangeal joint; therefore, the reconstruction is focused on both the thumb and fingers. Thumb amputation level, integrity of the first basal joint, and functionality of the thenar muscles can be used to subdivide type II. Functional reconstruction should consider the patient's desire and vocational needs. The finger left with adequate functional length is assessed for its location, level of amputation, and joint motion, especially the proximal interphalangeal joint. The goal is to use the reliable techniques of toe-to-hand surgery to reconstruct more opposable units, at least two fingers, whether adjacent to each other or not, and the thumb, when needed, to achieve a functionally and aesthetically better hand instead of a functionally adequate hand, with a more acceptable to ideally natural hand cascade. Strategic, individualized toe transfer(s) is the key element in fulfilling the goals of this operation whether single or multiple toes are transplanted.

Claw finger is a sequela of fingers without intrinsic function. Claw toe deformity is common after toe transfer, as simultaneous intrinsic reconstruction has yet to be reported in the literature. The authors present their experience of simultaneous tendon transfer during second-toe transplantation. Seven second-toe transfers were performed in five metacarpal-like and metacarpal hands. The Stiles-Bunnell tendon transfer was incorporated into toe transfers. Toe lumbrical tendons were repaired to the flexor digitorum sublimis of the same recipient digit. The active motion values of the proximal interphalangeal joint were 61 ± 9.5 degrees and 36 ± 6.4 degrees in the middle and ring fingers, respectively. The extension lag overall was 19.9 ± 9.9 degrees. The transferred toe proximal interphalangeal joints had minimal extensor lag with the metacarpophalangeal joint in flexion position. The flexion sweep of the toe was improved by the intrinsic reconstruction. The patients were able to use the transferred toes for sophisticated daily activities. From the results seen, simultaneous intrinsic reconstruction appears to enhance the dexterity and thus function of transferred toes., Clinical Question/level of Evidence: Therapeutic, IV.

Toe-to-finger transplantation is intimately related to the development of microsurgical free tissue transplantation, which is one of the most important advances in the history of reconstructive surgery. It is also generally acknowledged that a mangled hand with massive tissue loss and amputation of multiple digits presents a challenge for plastic and reconstructive surgeons. In this retrospective study we reviewed 11 cases of primary one-stage post-traumatic reconstruction of complex fingerless hands using a combination of toe-to-finger and free tissue transplantation performed in Shanghai Jiao Tong University affiliated Sixth People's Hospital and Shanghai Jiao Tong University School of Medicine affiliated Ninth People's Hospital from January 2001 to November 2014. Primary healing was achieved in 10 cases, while in the other case partial flap loss was documented and secondary healing was achieved by skin grafting. We concluded from this study that, by selecting suitable patients, use of a combination of toe-to-finger and free tissue transplantation may provide an alternative option for mangled hand salvage with satisfactory functional and esthetic results., (Copyright © 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Vascularized toe joint transfer for finger proximal interphalangeal joint reconstruction can result in sub-optimal arc of motion and extension lag due to inappropriate intercalated bony segment length. We investigated the impact of intercalated segment length on passive arc of motion and extension lag of the reconstructed proximal interphalangeal joint. Cadaveric intercalated joint grafts were harvested from lesser toes and transferred to cadaveric fingers. The pre-determined finger proximal interphalangeal joint defect size was 2 cm. Three different intercalated segment lengths were inserted and resulting proximal interphalangeal joint arc of motion and extension lag were measured. The average arc of motion of finger proximal interphalangeal joints was 81° and 54° for toe proximal interphalangeal joints. Long intercalated segments had an average arc of motion of 30° with 32° extension lag. Equal-length intercalated segments had an average 49° arc of motion with 15° extension lag. Short intercalated segments had an average arc of motion of 71° with 8° extension lag. Shorter intercalated segments provide the greatest reduction in extension lag.

We report 2 cases of extensive soft tissue defects simultaneously affecting the palm and dorsum of the hand. The defect was covered with a Siamese flap combination consisting of a free, distally extended lateral upper arm flap with microvascular anastomosis, and a posterior interosseous artery flap. We discuss possible indications, the operative technique and advantages versus disadvantages of this rarely applied flap combination., Competing Interests: Interessenkonflikt: Nein., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objective: To report preoperative planning using 3D printing to plan thumb reconstructions with second toe transplant., Methods: Between December 2013 and October 2015, the thumbs of five patients with grade 3 thumb defects were reconstructed using a wrap-around flap and second toe transplant aided by 3D printing technology. CT scans of hands and feet were analyzed using Boholo surgical simulator software (www.boholo.com). This allowed for the creation of a mirror image of the healthy thumb using the uninjured thumb. Using 3D images of the reconstructed thumb, a model of the big toe and the second toe was created to understand the dimensions of the donor site. This model was also used to repair the donor site defect by designing appropriate iliac bone and superficial circumflex iliac artery flaps. The polylactic acid model of the donor toes and reconstructed thumb was produced using 3D printing. Surgically, the wrap-around flap of the first dorsal metatarsal artery and vein combined with the joint and bone of the second toe was based upon the model donor site. Sensation was reconstructed by anastomosing the dorsal nerve of the foot and the plantar digital nerve of the great toe. Patients commenced exercises 2 weeks after surgery., Results: All reconstructed thumbs survived, although partial flap necrosis occurred in one case. This was managed with regular dressing changes. Patients were followed up for 3-15 months. The lengths of the reconstructed thumbs are 34-49 mm. The widths of the thumb nail beds are 16-19 mm, and the thickness of the digital pulp is 16-20 mm. The thumb opposition function was 0-1.5 cm; the extension angle was 5°-20° (mean, 16°), and the angle of flexion was 38°-55° (mean, 47°). Two-point discrimination was 9-11 mm (mean, 9.6 mm). The reconstructed thumbs had good appearance, function and sensation. Based on the criteria set forth by the Standard on Approval of Reconstructed Thumb and Finger Functional Assessment of the Chinese Medical Association, the results were considered excellent for four cases and good for one case. The success rate was 100%., Conclusions: When planning a wrap-around flap and second toe transplant to reconstruct a thumb, both the donor and recipient sites can be modeled using 3D printing. This can shorten the operative time by supplying digital and accurate schematics for the operation. It can also optimize the function and appearance of the reconstructed thumb while minimizing damage to the donor site., (© 2017 Chinese Orthopaedic Association and John Wiley & Sons Australia, Ltd.)

Background: Toe-to-thumb transfer has become the gold standard for thumb reconstruction, but in badly mutilated hands, additional soft tissue coverage may be required or a suitable recipient artery may not be available. There are only 3 case reports describing the successful use of a reverse radial forearm flap for coverage of a soft tissue defect around the thumb as well as providing arterial inflow for a toe transfer, performed either simultaneously or secondarily. Methods: A single surgeon's experience of all toe-to-hand transfers performed in conjunction with a reverse radial forearm flap between 1995 and 2014 was reviewed, including patient demographics, type of toe transfer and vascular pedicle, whether immediate or secondary, follow-up, and complications. Results: Eight toe-to-hand transfers were performed in 7 patients-3 children (age range, 3-15 years) and 4 adults (age range, 19-39 years). Three patients underwent primary toe-to-thumb transfer simultaneously with a reverse radial forearm flap, and 5 patients underwent secondary toe-to-hand transfer between 4 months and 2½ years after an initial reverse radial forearm flap. All toe transfers survived completely. Average follow-up was 5.1 years. All patients were satisfied with the function and appearance of their reconstructed thumb. Conclusion: The reverse radial forearm flap is a very reliable procedure as a "Sister" or "Siamese" flap to provide immediate arterial inflow to a simultaneous toe-to-thumb transfer, or to provide primary soft tissue coverage on the radial aspect of the hand and subsequently provide a recipient arterial inflow for a secondary toe transfer., Competing Interests: Declaration of Conflicting Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

When used to reconstruct a finger proximal interphalangeal joint, a free toe interphalangeal joint, without modification, cannot meet the motion demands of the finger to allow palm touchdown. This limitation is the direct result of the toe interphalangeal joint having an intrinsic arc of motion that delivers less flexion than that of a normal functioning finger proximal interphalangeal joint. By modifying the inset of the transferred joint to an extra-anatomical more proximal position, this limitation can be overcome. With a mathematical justification highlighted by a clinical illustration, we demonstrate the feasibility and utility of this "proximalization" technique., (Copyright © 2017 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: We report the use of distraction lengthening of the middle phalanx after vascularized second toe transfer for middle finger reconstruction to lengthen the digit to match the index and ring fingers., Methods: We performed a retrospective review of 3 patients with a mean follow-up of 30 months., Results: A mean increase of 2.0 cm in the length in the digit was achieved. The range of motion at the proximal interphalangeal joint was preserved and bony union was seen at the distraction site in all 3 cases. All patients had an excellent functional and aesthetic outcome., Conclusions: Distraction lengthening of vascularized toe transfers is a feasible undertaking., Type of Study/level of Evidence: Therapeutic V., (Copyright © 2017 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)