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Single third-toe transfer in hand reconstruction
Single Third-toe Transfer in Hand Reconstruction Fu-Chan Wei, MD, Taipei, Taiwan, Kenneth K. Yim, MD, Stanford, CA Eighteen third-toe transfers to the hand were performed from 1984 to 1993 in 15 patients. These patients had multiple amputations, and follow-up ranged from 5 to 78 months with an average of 27 months. Single third-toe-to-hand transfer was elected when (1) the second toe was not available or not suitable for transfer, (2) the second toe was located in the same foot where the great toe had been transferred to the thumb and the second toe was, therefore, spared for gait, or (3) the third toe was a better size match. (J Hand Surg 1995;20A:388-394.)
Toe transfers have been used to replace missing digits with success.l-l~ Various combinations of great toe, second toe, bilateral second toe and combined secondand third-toe transfers have been used to restore multiple missing digits in patients with multiple amputations. 1'7'1M4 The third toe has been transferred in combination with another toe as a unit (e.g., combined second and third toes, combined third and fourth toes, or combined third, fourth, and fifth toes). 1,2,12,15,16The use of a single third toe for finger reconstruction is relatively uncommon. 1~ A series of 18 such third-toe transfers is presented.
all 10 digits (Table 1). Twenty hands were injured, and 72 digits were amputated in these 15 patients. On average, there were 4 amputated digits per hand and 5 amputated digits per patient (Table 2). All patients except two had other toe-to-hand transfers. Three patients had simultaneous bilateral third-toe transfers. Forty-nine digits were reconstructed in these 15 patients. Thirty-one digits were reconstructed by toes other than the third toe (Table 3). The most common recipient location for the third toe was the middle finger. Patients were reviewed and follow-up ranged from 5 to 78 months with an average of 27 months.
Materials and Methods
Results
From January 1984 to June 1993, 18 single thirdtoe transfers were performed in 15 patients, 11 males and 4 females, whose average age was 25 years. The mechanism of injury was crush and avulsion in all except one patient. Five patients had digits amputated in both hands, and two patients had amputation of
Seventeen toes survived completely and one partially necrosed. Five re-explorations for vascular compromise were necessary in four toes. One of these four toes required a second exploration. Three toes were completely salvaged and one suffered partial necrosis (Table 4). Reasons for re-exploration are listed in Table 5. Four transfers had complications. One toe required shortening for partial necrosis. Two toes had partial skin loss, one required a split-thickness skin graft for coverage and the other healed spontaneously. Rupture of the flexor tendon was noted in one patient 6 weeks after transfer. All complications occurred in transfers where re-exploration for vascular compromise was necessary. In this series, the most common reason for using the third toe instead of the second toe was absence of the second toe. Twelve third toes were used because second
From the Departmentof Plastic and ReconstructiveSurgery,Chang Gung MemorialHospitaland Medical College,Taipei,TaiwanR.O.C., and the Division of Plastic and Reconstructive Surgery, Stanford UniversityMedicalCenter, Stanford,CA. Received for publication Jan. 31, 1994; accepted in revised form Nov. 2, 1994. No benefitsin any formhave been receivedor will be receivedfrom a commercialparty related directlyor indirectlyto the subject of this article. Reprint requests: Fu-Chan Wei, MD, Department of Plastic and ReconstructiveSurgery,Chang GungMemorialHospital, 199 Tun Hwa North Road, Taipei,Taiwan,R.O.C. 388
The Journal of Hand Surgery
The Journal of Hand Surgery / Vol. 20A No. 3 May 1995
389
Table 1. Patient Data
Sex
Injured Hand
No. of Digits Involved
23 29 21 32 30 22 16 41 24 19 23
M M M F M M M M F M M
Right Both Both Both Left Left Right Left Both Left Both
4 10 10 4 3 4 3 1 8 4 8
23 18 26 23
F M M F
Right Left Right Left
2 4 3 5
Patient
Age (years)
1* 2 3 4 5 6* 7 8 9 10 11 * 12 13 14 15
Nature of Injury
Multiple Transplant
Crush Crush Crush Crush Crush Crush Crush Crush Sharp Crush Crush and avulsion Crush Crush Crush Crush and avulsion
DOI
DOS
Both Sequential Sequential Both Simultaneous Simultaneous Both Sequential!" Both Both Both
8/7/89 3/25/90 10/7/91 3/91 11/26/88 4/26/85 3/1/87 1/8/90 10/27/90 1/31/91 8/11/92
7/17/91 3/9/92 6/10/92 6/28/93 1/11/89 9/18/85 3/23/88 7/4/90 4/6/92 8/12/91 6/21/93
No Both Both Both
2/25/89 ? 1/5/84 11/30/88
5/24/89 11/20/91 1/30/84 6/20/90
*Bilateral third-toe transfers, tPatient had previous toe-to-hand transfer for contralateral hand injuries. DOI, date of injury; DOS, date of surgery; Both, both sequential and simultaneous transplantations.
toes previously were harvested for toe-to-hand transfers. Patient 6 had amputation of the index, middle, ring, and little fingers. Third toes were used for index finger and middle finger reconstructions to save second toes for ring finger and little finger reconstructions. In patient 12, the third toe was used because it provided a better size match with the remaining fingers. In the remaining three instances, the second toe was spared for gait because it was located in the same foot where the great toe had been transferred (Table 3). Moving two-point discrimination in 10 digits ranged from 3 to 14 mm (mean, 8 mm). All donor sites were closed primarily. There was no significant donor site morbidity, even in feet from which multiple toes were harvested. No patient experienced any gait problems, and no special shoe or footwear was required in any patient.
Case Reports Case 1 A 21-year-old man had multiple digit amputations. Thumb and thenar muscles were uninjured. Table 2. Patient and Injury Profile No. of patients Male:Female Average age in years (range) Total hands injured Total digits amputated Digits amputated per hand Digits amputated per patient
15 11:4 25 (16-41) 20 73 4 (73/20) 5 (73/15)
Replantation of the amputated digits failed. Four months later second toes from the right and left feet were transferred to replace the index and long fingers (Fig. 1). Nineteen months later the third toes from the right and left feet were transferred to restore length in the ring and little fingers and to improve gross grip (Figs. 2 4 ) . Moving two-point discrimination was 3 mm in the ring finger and 4 mm in the little finger at 16 months. Range of motion (flexion/extension) of the distal interphalangeal joint was 25~ ~ and 25 ~ ~ in the ring and little fingers, respectively. No donor site and gait problems were noted by the patient. Case 1 5
A 27-year-old woman had a crush injury to the left hand with amputation of the thumb and all fingers at proximal phalanx level. Coverage was obtained with a pedicle groin flap at another hospital. A left, trimmed great toe and a right second toe were transferred simultaneously to the left thumb and index finger in March 1990 (Fig. 5). In consultation with the patient it was decided that additional toe transfer to the middle finger position was required. Since the remaining second toe was in the same foot where the great toe previously was harvested, the third toe was selected (Figs. 6-8). The third common digital artery was used as a pedicle and anastomosed to the ulnar digital artery of the long finger at the proximal phalangeal level. The donor site was closed primarily. Tridigital chuck pinch was restored (Fig. 9). Moving
390
Wei and Kim / Single Third-toe Transfer T a b l e 3. O t h e r P r o c e d u r e s
Patient
Donor Foot
Recipient Location
Recipient Level
la
R
R Ring
MP
1b 2
L R
R Little L Thumb
MP PP
3
L
L Middle
MC
4
L
R Ring
MP
5
L
L Middle
MP
6a
L
L Index
MP
6b 7
R R
L Middle R Ring
MP MP
8
L
L Index
MP
9
L
R Ring
MP
10
L
L Ring
MP
lla
R
L Index
PP
1l b 12 13
L L L
L Middle R Middle L Little
PP MP PP
14
L
R Little
PP
15
R
L Middle
PP
Other Toe-to-Hand Procedures R 2nd to R middle L 2nd to R index Same L 2nd and 3rd to R middle and ring R 4th to L ring R Great toe to R thumb L 2nd to R thumb R 3rd and 4th to R index and middle R 2nd to L thumb L 2nd to R ring [failed] R 2nd to R middle L 2nd to L ring R 2nd to L index None Same R 2nd to R index L 2nd to R middle Previous hand injuries L Great toe to R thumb R 2nd and 3rd to R middle and ring L 2nd to L index R 2nd to R thumb L 2nd to L index R 2nd to L middle R 2nd to L middle L 2nd to L index Same None L 2nd to L index R 2nd to L middle L 2nd to L ring R 2nd to L middle R 2nd to L index L Great toe to L thumb
Reasons for 3rd Toe No 2nd toe available Same Remaining 2nd toe is adjacent to harvested great toe
No 2nd toe available
No 2nd toe available No 2nd toe available Saving 2nd toes for future use* Same No 2nd toe available Remaining 2nd toe is adjacent to harvested great toe
No 2nd toe available No 2nd toe available No 2nd toe available Same Better size match No 2nd toe available No 2nd toe available Remaining 2nd toe is adjacent to harvested great toe
*Patients had amputation of index, middle, ring and little fingers. Third toes were used for index finger and middle finger recostructions to save second toes for ring finger and little finger reconstructions. PP, proximal phalanx; MP, middle phalanx; MC, metacarpal.
two-point discrimination was 10 mm at 39 months. Distal interphalangeal joint range of, motion was 30~ ~ No special footwear was necessary. The patient had no complaints of the donor site and gait, and reported no change in activity level (Fig. 10).
Discussion The majority of the patients undergoing third-toe transfer already have had transfer of the great toe or second toe. In order to avoid scar tissue or to preserve the second metatarsal pedicle for future trans-
fers, we recommend using the third common plantar digital artery as the vascular pedicle. When a short pedicle is needed, the proper digital artery can be used. In this series, the proper plantar digital artery, third common plantar digital artery, and second dorsal metatarsal artery were used. The second dorsal metatarsal artery is usually of inadequate caliber and, therefore, it is technically simpler and quicker to proceed directly to dissection of the plantar vascular pedicle and use a vein graft if necessary. Nerve and tendon dissections are similar to other toe dissections. The third toe is disarticulated
The Journal of Hand Surgery / Vol. 20A No. 3 May 1995
391
Table 4. Outcome of Transplantation
Patient la
lb 2 3 4 5 6a 6b 7 8 9 10 lla llb 12 13 14 15
Number of Re-explorations 0 0 0 0 1 1 0 1 0 0 0 0 0 0 2 0 0 0
Results
Complications
Total survival Total survival Total survival Total survival Total survival Partial survival Total survival Total survival Total survival Total survival Total survival Total survival Total survival Total survival Total survival Total survival Total survival Total survival
None None None None Yes Yes None Yes None None None None None None Yes None None None
Table 5. Complications
Patient
No. of Hours Explorations After Transplant
Exploration Findings
Salvage Procedure
Survival
4
1
5
Venous compression
Release compression
Total
5
1
20
Arterial thrombosis
Vein graft artery
Partial
6b 12
1 2
108 29 (lst)
Arterial compression Arterial spasm
Release compression Relieve spasm
Total Total
52 (2nd)
Arterial thrombosis
Vein graft artery
Total
Figure 1. Right and left second toes transferred to right index and long fingers.
Complications Flexor tendon rupture 8/10/93 Shortening on 1/25/89 Partial skin loss Partial skin loss; cold intolerance Same
Figure 2. Right and left third toes were used to reconstruct the ring and little fingers.
392
Wei and Kim / Single Third-toe Transfer
Figure 3. Pulp-to-pulp pinch between thumb and ring finger.
Figure 6. Dissection of the lateral proper digital artery and the third common digital artery of the third toe. The second toe previously was harvested.
Figure 4. Pulp-to-pulp pinch between little finger and thumb.
Figure 7. Third toe with the third common digital artery as vascular pedicle.
Figure 5. Trimmed great toe and right second toe transferred to thumb and index finger to provide tridigital chuck pinch.
Figure 8. Appearance after transplantation.
The Journal of Hand Surgery / Vol. 20A No. 3 May 1995
393
The third toe can also be used for aesthetic reasons when it provides a better size match to the remaining fingers than the second toe. After the great toe is harvested, the center of weight-bearing pressure shifts lateraily to the second metatarsal head. 22 Harvesting the great toe and second toe in the same foot may result in problems with gait; when that clinical situation is present, we recommend transferring the third toe.
References F i g u r e 9. Tridigital chuck pinch.
F i g u r e 10. Appearance of feet after toe transfer.
at the metatarsophalangeal joint so that the donor wound can be closed. Although additional toe-to-finger transfer after restoration of tridigital pinch is controversial, there are additional benefits from such surgery. The storage function of the hand is a valuable supplement to the pick up function of the hand. 19 When the ring or long finger is missing, small objects may fall through the gap in grasping and the storage function of the hand is impaired. 2'12The loss of the digital arcade in this situation is also obvious and can be aesthetically and socially unacceptable. 2~ Additional microvascular toe-to-finger transfer can restore the digital arcade and storage function of the hand. 2'7'9'u'12'21 The breadth of the palm and grip strength, both reduced in ray amputation, are preserved in toe-to-finger transfer. 1,2,12 A third toe can b e u s e d for t o e - t o - h a n d transfer instead o f the s e c o n d toe in severe mutilating h a n d injuries w h e n the s e c o n d toe is not available or not suitable due to p r e v i o u s injury, surgery, or deformity.
1. Buncke GM, Buncke HJ, Oliva A, Lineaweaver WC, Siko PP. Hand reconstruction with partial toe and multiple transplants. Clin Plast Surg 1992;19:859-70. 2. Buncke HJ. Digital reconstruction by second-toe transplantation. In: Buncke HJ, ed. Microsurgery: transplantation, replantation: an atlas text. Philadelphia: Lea & Febiger, 1991:61-101. 3. Foucher G, Moss AL. Microvascular second toe to finger transfer: a statistical analysis of 55 transfers. Br J Plast Surg 1991;44:87-90. 4. Gu YD, Zhang GM, Cheng DS, Yan JG, Chen XM. Free toe transfer for thumb and finger reconstruction in 300 cases. Plast Reconstr Surg 1993;91:693-700. 5. Leung PC. Finger reconstruction using toe transplantation. J Hand Surg 1986;11:20-2. 6. O'Brien B, MacLeod AM, Sykes PJ, Browning FS, Threlfall GN. Microvascular second toe transfer for digital reconstruction. J Hand Surg 1978; 3:123-33. 7. Wei FC, Chen HC, Chuang CC, Noordhoff MS. Simultaneous multiple toe transfers in hand reconstruction. Plast Reconstr Surg 1988;81:366-77. 8. Wei FC, Chen HC, Chuang DC, Chen S, Noordhoff MS. Second toe wrap-around flap. Plast Reconstr Surg 1991 ;88:837-43. 9. Wei FC, Epstein MD, Chen HC, Chuang CC, Chen HT. Microsurgical reconstruction of distal digits following mutilating hand injuries: results in 121 patients. Br J Plast Surg 1993;46:181-6. 10. Yoshimura M. Toe-to-hand transfer. Plast Reconstr Surg 1980;66:74-84. 11. Wei FC, Colony LH. Microsurgical reconstruction of opposable digits in mutilating hand injuries. Clin Plast Surg 1989;16:491-504. 12. Valanri FA, Buncke HJ. Thumb and finger reconstruction by toe-to-hand transfer. Hand Clin 1992;8:551-74. 13. Leung PC. Double toe transfers. J Hand Surg 1987;12: 162-5. 14. Gordon L, Leitner DW, Buncke HJ, Alpert BS. Hand reconstruction for multiple amputations by double microsurgical toe transplantation. J Hand Surg 1985;10:218-25. 15. Chen HC, Tang YB, Wei FC, Noordhoff MS. Finger reconstruction with triple toe transfer from the same foot for a patient with a special job and previous foot trauma. Ann Ptast Surg 1991;27:272-7. 16. Pisarek W. Transfer of the third, fourth and fifth toes for one-stage reconstruction of the thumb and two fingers. Br J Plast Surg 1990;43:244-6.
394
Wei and Kim / Single Third-toe Transfer
17. Egloff D. Surgery of the hand. Free tissue transfers by nerve and vascular microanastomoses. Geneva:Editions M&lecine et Hygiene, 1984:83-4. 18. Holle J, Freilinger G, Mandl H, Frey M. Grip reconstruction by double-toe transplantation in cases of a fingedess hand and a handless arm. Plast Reconstr Surg 1982;69:962-8. 19. Moberg E: Fingertip function and evaluation of its sensibility. In: Foucher G, ed. Fingertip and nailbed injuries. London: Churchill Livingstone, 199t: 10-16.
20. Leung PC: The Chinese culture and hand reconstruction. In: Landi A, ed, Reconstruction of the thumb. London: Chapman and Hall, 1989:11-16. 21. Wei FC, Colony LH, Chen HC, Chuang CC, Noordhoff MS. Combined second and third toe transfer. Plast Reconstr Surg 1989;84:651-61. 22. Poppen NK, Norris TR, Buncke HJ. Evaluation of sensibility and function with microsurgical free tissue transfer of the great toe to the hand for thumb reconstruction. J Hand Surg 1983;8:516-31.
Toe transfers have been used to replace missing digits with success.l-l~ Various combinations of great toe, second toe, bilateral second toe and combined secondand third-toe transfers have been used to restore multiple missing digits in patients with multiple amputations. 1'7'1M4 The third toe has been transferred in combination with another toe as a unit (e.g., combined second and third toes, combined third and fourth toes, or combined third, fourth, and fifth toes). 1,2,12,15,16The use of a single third toe for finger reconstruction is relatively uncommon. 1~ A series of 18 such third-toe transfers is presented.
all 10 digits (Table 1). Twenty hands were injured, and 72 digits were amputated in these 15 patients. On average, there were 4 amputated digits per hand and 5 amputated digits per patient (Table 2). All patients except two had other toe-to-hand transfers. Three patients had simultaneous bilateral third-toe transfers. Forty-nine digits were reconstructed in these 15 patients. Thirty-one digits were reconstructed by toes other than the third toe (Table 3). The most common recipient location for the third toe was the middle finger. Patients were reviewed and follow-up ranged from 5 to 78 months with an average of 27 months.
Materials and Methods
Results
From January 1984 to June 1993, 18 single thirdtoe transfers were performed in 15 patients, 11 males and 4 females, whose average age was 25 years. The mechanism of injury was crush and avulsion in all except one patient. Five patients had digits amputated in both hands, and two patients had amputation of
Seventeen toes survived completely and one partially necrosed. Five re-explorations for vascular compromise were necessary in four toes. One of these four toes required a second exploration. Three toes were completely salvaged and one suffered partial necrosis (Table 4). Reasons for re-exploration are listed in Table 5. Four transfers had complications. One toe required shortening for partial necrosis. Two toes had partial skin loss, one required a split-thickness skin graft for coverage and the other healed spontaneously. Rupture of the flexor tendon was noted in one patient 6 weeks after transfer. All complications occurred in transfers where re-exploration for vascular compromise was necessary. In this series, the most common reason for using the third toe instead of the second toe was absence of the second toe. Twelve third toes were used because second
From the Departmentof Plastic and ReconstructiveSurgery,Chang Gung MemorialHospitaland Medical College,Taipei,TaiwanR.O.C., and the Division of Plastic and Reconstructive Surgery, Stanford UniversityMedicalCenter, Stanford,CA. Received for publication Jan. 31, 1994; accepted in revised form Nov. 2, 1994. No benefitsin any formhave been receivedor will be receivedfrom a commercialparty related directlyor indirectlyto the subject of this article. Reprint requests: Fu-Chan Wei, MD, Department of Plastic and ReconstructiveSurgery,Chang GungMemorialHospital, 199 Tun Hwa North Road, Taipei,Taiwan,R.O.C. 388
The Journal of Hand Surgery
The Journal of Hand Surgery / Vol. 20A No. 3 May 1995
389
Table 1. Patient Data
Sex
Injured Hand
No. of Digits Involved
23 29 21 32 30 22 16 41 24 19 23
M M M F M M M M F M M
Right Both Both Both Left Left Right Left Both Left Both
4 10 10 4 3 4 3 1 8 4 8
23 18 26 23
F M M F
Right Left Right Left
2 4 3 5
Patient
Age (years)
1* 2 3 4 5 6* 7 8 9 10 11 * 12 13 14 15
Nature of Injury
Multiple Transplant
Crush Crush Crush Crush Crush Crush Crush Crush Sharp Crush Crush and avulsion Crush Crush Crush Crush and avulsion
DOI
DOS
Both Sequential Sequential Both Simultaneous Simultaneous Both Sequential!" Both Both Both
8/7/89 3/25/90 10/7/91 3/91 11/26/88 4/26/85 3/1/87 1/8/90 10/27/90 1/31/91 8/11/92
7/17/91 3/9/92 6/10/92 6/28/93 1/11/89 9/18/85 3/23/88 7/4/90 4/6/92 8/12/91 6/21/93
No Both Both Both
2/25/89 ? 1/5/84 11/30/88
5/24/89 11/20/91 1/30/84 6/20/90
*Bilateral third-toe transfers, tPatient had previous toe-to-hand transfer for contralateral hand injuries. DOI, date of injury; DOS, date of surgery; Both, both sequential and simultaneous transplantations.
toes previously were harvested for toe-to-hand transfers. Patient 6 had amputation of the index, middle, ring, and little fingers. Third toes were used for index finger and middle finger reconstructions to save second toes for ring finger and little finger reconstructions. In patient 12, the third toe was used because it provided a better size match with the remaining fingers. In the remaining three instances, the second toe was spared for gait because it was located in the same foot where the great toe had been transferred (Table 3). Moving two-point discrimination in 10 digits ranged from 3 to 14 mm (mean, 8 mm). All donor sites were closed primarily. There was no significant donor site morbidity, even in feet from which multiple toes were harvested. No patient experienced any gait problems, and no special shoe or footwear was required in any patient.
Case Reports Case 1 A 21-year-old man had multiple digit amputations. Thumb and thenar muscles were uninjured. Table 2. Patient and Injury Profile No. of patients Male:Female Average age in years (range) Total hands injured Total digits amputated Digits amputated per hand Digits amputated per patient
15 11:4 25 (16-41) 20 73 4 (73/20) 5 (73/15)
Replantation of the amputated digits failed. Four months later second toes from the right and left feet were transferred to replace the index and long fingers (Fig. 1). Nineteen months later the third toes from the right and left feet were transferred to restore length in the ring and little fingers and to improve gross grip (Figs. 2 4 ) . Moving two-point discrimination was 3 mm in the ring finger and 4 mm in the little finger at 16 months. Range of motion (flexion/extension) of the distal interphalangeal joint was 25~ ~ and 25 ~ ~ in the ring and little fingers, respectively. No donor site and gait problems were noted by the patient. Case 1 5
A 27-year-old woman had a crush injury to the left hand with amputation of the thumb and all fingers at proximal phalanx level. Coverage was obtained with a pedicle groin flap at another hospital. A left, trimmed great toe and a right second toe were transferred simultaneously to the left thumb and index finger in March 1990 (Fig. 5). In consultation with the patient it was decided that additional toe transfer to the middle finger position was required. Since the remaining second toe was in the same foot where the great toe previously was harvested, the third toe was selected (Figs. 6-8). The third common digital artery was used as a pedicle and anastomosed to the ulnar digital artery of the long finger at the proximal phalangeal level. The donor site was closed primarily. Tridigital chuck pinch was restored (Fig. 9). Moving
390
Wei and Kim / Single Third-toe Transfer T a b l e 3. O t h e r P r o c e d u r e s
Patient
Donor Foot
Recipient Location
Recipient Level
la
R
R Ring
MP
1b 2
L R
R Little L Thumb
MP PP
3
L
L Middle
MC
4
L
R Ring
MP
5
L
L Middle
MP
6a
L
L Index
MP
6b 7
R R
L Middle R Ring
MP MP
8
L
L Index
MP
9
L
R Ring
MP
10
L
L Ring
MP
lla
R
L Index
PP
1l b 12 13
L L L
L Middle R Middle L Little
PP MP PP
14
L
R Little
PP
15
R
L Middle
PP
Other Toe-to-Hand Procedures R 2nd to R middle L 2nd to R index Same L 2nd and 3rd to R middle and ring R 4th to L ring R Great toe to R thumb L 2nd to R thumb R 3rd and 4th to R index and middle R 2nd to L thumb L 2nd to R ring [failed] R 2nd to R middle L 2nd to L ring R 2nd to L index None Same R 2nd to R index L 2nd to R middle Previous hand injuries L Great toe to R thumb R 2nd and 3rd to R middle and ring L 2nd to L index R 2nd to R thumb L 2nd to L index R 2nd to L middle R 2nd to L middle L 2nd to L index Same None L 2nd to L index R 2nd to L middle L 2nd to L ring R 2nd to L middle R 2nd to L index L Great toe to L thumb
Reasons for 3rd Toe No 2nd toe available Same Remaining 2nd toe is adjacent to harvested great toe
No 2nd toe available
No 2nd toe available No 2nd toe available Saving 2nd toes for future use* Same No 2nd toe available Remaining 2nd toe is adjacent to harvested great toe
No 2nd toe available No 2nd toe available No 2nd toe available Same Better size match No 2nd toe available No 2nd toe available Remaining 2nd toe is adjacent to harvested great toe
*Patients had amputation of index, middle, ring and little fingers. Third toes were used for index finger and middle finger recostructions to save second toes for ring finger and little finger reconstructions. PP, proximal phalanx; MP, middle phalanx; MC, metacarpal.
two-point discrimination was 10 mm at 39 months. Distal interphalangeal joint range of, motion was 30~ ~ No special footwear was necessary. The patient had no complaints of the donor site and gait, and reported no change in activity level (Fig. 10).
Discussion The majority of the patients undergoing third-toe transfer already have had transfer of the great toe or second toe. In order to avoid scar tissue or to preserve the second metatarsal pedicle for future trans-
fers, we recommend using the third common plantar digital artery as the vascular pedicle. When a short pedicle is needed, the proper digital artery can be used. In this series, the proper plantar digital artery, third common plantar digital artery, and second dorsal metatarsal artery were used. The second dorsal metatarsal artery is usually of inadequate caliber and, therefore, it is technically simpler and quicker to proceed directly to dissection of the plantar vascular pedicle and use a vein graft if necessary. Nerve and tendon dissections are similar to other toe dissections. The third toe is disarticulated
The Journal of Hand Surgery / Vol. 20A No. 3 May 1995
391
Table 4. Outcome of Transplantation
Patient la
lb 2 3 4 5 6a 6b 7 8 9 10 lla llb 12 13 14 15
Number of Re-explorations 0 0 0 0 1 1 0 1 0 0 0 0 0 0 2 0 0 0
Results
Complications
Total survival Total survival Total survival Total survival Total survival Partial survival Total survival Total survival Total survival Total survival Total survival Total survival Total survival Total survival Total survival Total survival Total survival Total survival
None None None None Yes Yes None Yes None None None None None None Yes None None None
Table 5. Complications
Patient
No. of Hours Explorations After Transplant
Exploration Findings
Salvage Procedure
Survival
4
1
5
Venous compression
Release compression
Total
5
1
20
Arterial thrombosis
Vein graft artery
Partial
6b 12
1 2
108 29 (lst)
Arterial compression Arterial spasm
Release compression Relieve spasm
Total Total
52 (2nd)
Arterial thrombosis
Vein graft artery
Total
Figure 1. Right and left second toes transferred to right index and long fingers.
Complications Flexor tendon rupture 8/10/93 Shortening on 1/25/89 Partial skin loss Partial skin loss; cold intolerance Same
Figure 2. Right and left third toes were used to reconstruct the ring and little fingers.
392
Wei and Kim / Single Third-toe Transfer
Figure 3. Pulp-to-pulp pinch between thumb and ring finger.
Figure 6. Dissection of the lateral proper digital artery and the third common digital artery of the third toe. The second toe previously was harvested.
Figure 4. Pulp-to-pulp pinch between little finger and thumb.
Figure 7. Third toe with the third common digital artery as vascular pedicle.
Figure 5. Trimmed great toe and right second toe transferred to thumb and index finger to provide tridigital chuck pinch.
Figure 8. Appearance after transplantation.
The Journal of Hand Surgery / Vol. 20A No. 3 May 1995
393
The third toe can also be used for aesthetic reasons when it provides a better size match to the remaining fingers than the second toe. After the great toe is harvested, the center of weight-bearing pressure shifts lateraily to the second metatarsal head. 22 Harvesting the great toe and second toe in the same foot may result in problems with gait; when that clinical situation is present, we recommend transferring the third toe.
References F i g u r e 9. Tridigital chuck pinch.
F i g u r e 10. Appearance of feet after toe transfer.
at the metatarsophalangeal joint so that the donor wound can be closed. Although additional toe-to-finger transfer after restoration of tridigital pinch is controversial, there are additional benefits from such surgery. The storage function of the hand is a valuable supplement to the pick up function of the hand. 19 When the ring or long finger is missing, small objects may fall through the gap in grasping and the storage function of the hand is impaired. 2'12The loss of the digital arcade in this situation is also obvious and can be aesthetically and socially unacceptable. 2~ Additional microvascular toe-to-finger transfer can restore the digital arcade and storage function of the hand. 2'7'9'u'12'21 The breadth of the palm and grip strength, both reduced in ray amputation, are preserved in toe-to-finger transfer. 1,2,12 A third toe can b e u s e d for t o e - t o - h a n d transfer instead o f the s e c o n d toe in severe mutilating h a n d injuries w h e n the s e c o n d toe is not available or not suitable due to p r e v i o u s injury, surgery, or deformity.
1. Buncke GM, Buncke HJ, Oliva A, Lineaweaver WC, Siko PP. Hand reconstruction with partial toe and multiple transplants. Clin Plast Surg 1992;19:859-70. 2. Buncke HJ. Digital reconstruction by second-toe transplantation. In: Buncke HJ, ed. Microsurgery: transplantation, replantation: an atlas text. Philadelphia: Lea & Febiger, 1991:61-101. 3. Foucher G, Moss AL. Microvascular second toe to finger transfer: a statistical analysis of 55 transfers. Br J Plast Surg 1991;44:87-90. 4. Gu YD, Zhang GM, Cheng DS, Yan JG, Chen XM. Free toe transfer for thumb and finger reconstruction in 300 cases. Plast Reconstr Surg 1993;91:693-700. 5. Leung PC. Finger reconstruction using toe transplantation. J Hand Surg 1986;11:20-2. 6. O'Brien B, MacLeod AM, Sykes PJ, Browning FS, Threlfall GN. Microvascular second toe transfer for digital reconstruction. J Hand Surg 1978; 3:123-33. 7. Wei FC, Chen HC, Chuang CC, Noordhoff MS. Simultaneous multiple toe transfers in hand reconstruction. Plast Reconstr Surg 1988;81:366-77. 8. Wei FC, Chen HC, Chuang DC, Chen S, Noordhoff MS. Second toe wrap-around flap. Plast Reconstr Surg 1991 ;88:837-43. 9. Wei FC, Epstein MD, Chen HC, Chuang CC, Chen HT. Microsurgical reconstruction of distal digits following mutilating hand injuries: results in 121 patients. Br J Plast Surg 1993;46:181-6. 10. Yoshimura M. Toe-to-hand transfer. Plast Reconstr Surg 1980;66:74-84. 11. Wei FC, Colony LH. Microsurgical reconstruction of opposable digits in mutilating hand injuries. Clin Plast Surg 1989;16:491-504. 12. Valanri FA, Buncke HJ. Thumb and finger reconstruction by toe-to-hand transfer. Hand Clin 1992;8:551-74. 13. Leung PC. Double toe transfers. J Hand Surg 1987;12: 162-5. 14. Gordon L, Leitner DW, Buncke HJ, Alpert BS. Hand reconstruction for multiple amputations by double microsurgical toe transplantation. J Hand Surg 1985;10:218-25. 15. Chen HC, Tang YB, Wei FC, Noordhoff MS. Finger reconstruction with triple toe transfer from the same foot for a patient with a special job and previous foot trauma. Ann Ptast Surg 1991;27:272-7. 16. Pisarek W. Transfer of the third, fourth and fifth toes for one-stage reconstruction of the thumb and two fingers. Br J Plast Surg 1990;43:244-6.
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Wei and Kim / Single Third-toe Transfer
17. Egloff D. Surgery of the hand. Free tissue transfers by nerve and vascular microanastomoses. Geneva:Editions M&lecine et Hygiene, 1984:83-4. 18. Holle J, Freilinger G, Mandl H, Frey M. Grip reconstruction by double-toe transplantation in cases of a fingedess hand and a handless arm. Plast Reconstr Surg 1982;69:962-8. 19. Moberg E: Fingertip function and evaluation of its sensibility. In: Foucher G, ed. Fingertip and nailbed injuries. London: Churchill Livingstone, 199t: 10-16.
20. Leung PC: The Chinese culture and hand reconstruction. In: Landi A, ed, Reconstruction of the thumb. London: Chapman and Hall, 1989:11-16. 21. Wei FC, Colony LH, Chen HC, Chuang CC, Noordhoff MS. Combined second and third toe transfer. Plast Reconstr Surg 1989;84:651-61. 22. Poppen NK, Norris TR, Buncke HJ. Evaluation of sensibility and function with microsurgical free tissue transfer of the great toe to the hand for thumb reconstruction. J Hand Surg 1983;8:516-31.