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A Systematic Review of Outcomes of Toe-to-Thumb Transfers for Isolated Traumatic Thumb Amputation
PAPER 26 'SJEBZ 4FQUFNCFS t". $MJOJDBM1BQFS4FTTJPO.JDSPTVSHFSZ
Long-Term Donor Site Morbidity in Free Non-vascularized Toe Phalangeal Transfer
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Level 4 Evidence
Phalangeal growth distal to the donor phalanx is universally compromised. Metatarsal length proximal to the donor proximal phalanx is radiographically reduced in 48% of cases and metatarsal head width is reduced in all cases. Preoperative counselling should include discussion on long term donor site morbidity and alternative techniques. The authors would recommend attempts to restore the structural integrity of the toes after free phalangeal harvest such as that proposed by Bourke and Kay. The results of surgical procedures performed in childhood on the musculoskeletal system can only be adequately judged with long-term follow-up.
v Lorenzo Garagnani, MD Marc Gibson, MB, BSc Gillian Dawn Smith, FRCS
):105)&4*4 Free non-vascularized toe phalangeal transfer is an established surgical option for reconstruction of hypoplastic digits. Several studies, all with limited numbers and short follow-up, focus on the surgical technique and the outcome in the hand, but barely mention the donor site. It is stated that the donor site defect is usually minimal - this study has specifically tested this hypothesis with review of the donor site after long-term follow-up.
.&5)0%4 This is a retrospective cohort review of 40 children with hypoplastic digits who underwent 126 free non-vascularized toe phalangeal transfers between 1991 and 2007. Mean age at transfer was 40 months (range 7-125 months). Mean postoperative follow-up was 10 years (range 36-228 months). Median follow-up was 114 months (IQR 73-164 months). The Oxford Ankle Foot Questionnaire was administered to patients and families. Clinical review assessed toe length ratio, visible deformity, and stability of the donor toes. Radiographic measurements (n=19 toes) and photographic measurement (n=41 toes) were performed.
3&46-54 93.3% of patients and 88.8% of families interviewed reported variable degrees of dissatisfaction with the donor feet. This study has shown increasing foot deformity with age, with significant aesthetic deterioration. All patients have floppy unstable toes with visible shortening and deformity at long-term follow-up. On radiographs, phalangeal hypoplasia distal to the harvested phalanges was present in 100% of cases, metatarsal shortening in 48% of cases, and metatarsal head hypoplasia in 100% of donor rays. Radiographic and photographic measurement of donor toes length showed inversion of the normal toe length ratio in all donor toes.
PAPER 27 'SJEBZ 4FQUFNCFS t". $MJOJDBM1BQFS4FTTJPO.JDSPTVSHFSZ
A Systematic Review of Outcomes of Toe-to-Thumb Transfers for Isolated Traumatic Thumb Amputation Level 3 Evidence Pao-Yuan Lin, MD Sandeep J. Sebastin, MCh Shimpei Ono, MD, PhD Kevin C. Chung, MD, MS
M
):105)&4*4 We hypothesize that trimmed great toe transfer provides the best functional and aesthetic reconstruction of a thumb amputated distal to the metacarpophalangeal joint when compared to great toe, second toe, and wrap-around great toe transfer techniques (Figure 1).
.&5)0%4 A MEDLINE/ EMBASE and ISI search using “toe-to-thumb transfer combined with thumb injury and reconstruction” as keywords and limited to humans and the English language identified 633 studies. Studies were included in the review if they: (1) present primary data; (2) report 3 or more toe-to-thumb transfers for isolated complete traumatic thumb amputation through the proximal phalanx; (3) present functional outcome data. Additional data extracted from the studies meeting the inclusion criteria included demographic information, donor morbidity, and patient satisfaction.
46.."3:10*/54 ∙ ∙ ∙
There are functional and aesthetic problems with the donor site from free non-vascularized phalangeal transfer. Deformities of all donor toes have been identified at long-term follow-up. Normal toe length ratio is inverted in all donor toes at longterm follow-up.
v Speaker has nothing of financial value to disclose
3&46-54 25 studies representing 450 toe-to-thumb transfers met the inclusion criteria. They included 101 second toe transfers, 196 great toe transfers, 122 wrap-around transfers, and 31 trimmed toe transfers. The mean survival rate was 96.4%. No statistically significant differences could be detected amongst the 4 types
21
of toe-to-thumb transfers with regards to survival or any of the functional outcome parameters [arc of motion (AOM), total active motion (TAM), grip and pinch strength, and static two-point discrimination (2 PD)] (Figure 1).
46.."3:10*/54 ∙
∙
∙ ∙
The traditional teaching is that A great toe makes a great thumb because a great toe transfer results in better motion and superior strength compared to a second toe transfer. This study revealed that all 4 types of toe-to-thumb transfer procedures have predictably high survival rates and found no statistically significant differences in the factors of survival, AOM, TAM, grip and key pinch strength, and static 2-PD. There is no dominant technique that favors its selection based on the best available data from the literature. The selection of the techniques relies on the preference and expertise of the surgeon, and perhaps the patient's perception of the outcomes and donor site trade-offs.
3&'&3&/$&4 1. Morrison WA, O’Brien BM, MacLeod AM. Thumb reconstruction with a free neurovascular wrap-around flap from the big toe. J Hand Surg 1980;5A:575-583. 2. Poppen NK, Norris TR, Buncke HJ, Jr. Evaluation of sensibility and function with microsurgical free tissue transfer of the great toe to the hand for thumb reconstruction. J Hand Surg 1983;8A:516-531. 3. Doi K, Kuwata N, Kawai S. Reconstruction of the thumb with a free wrap-around flap from the big toe and an iliac-bone graft. J Bone Joint Surg 1985;67A:439-445. 4. Tsai TM, McCabe 217 S, Beatty ME. Second toe transfer for thumb reconstruction in multiple digit amputations including thumb and basal joint. Microsurgery 1987;8:146-153. 5. Wei FC, Chen HC, Chuang CC, Chen SH. Microsurgical thumb reconstruction with toe transfer: selection of various techniques. Plast Reconstr Surg 1994;93:345-357. 6. Chung KC, Wei FC. An outcome study of thumb reconstruction using microvascular toe transfer. J Hand Surg 2000;25A:651-658. 7. Woo SH, Kim JS, Seul JH. Immediate toe-to-hand transfer in acute hand injuries: overall results, compared with results for elective cases. Plast Reconstr Surg 2004;113:882-892. 8. Lee CK, Buncke GM. Great toe-to-thumb microvascular transplantation. Clin Plast Surg 2007;34:223-231. 9. Huang D, Wang HG, Wu WZ, Zhang HR, Lin H. Functional and aesthetic results of immediate reconstruction of traumatic thumb defects by toe-to-thumb transplantation. Int Orthop 2010. 10.Lee KS, Park JW, Chung WK. Thumb reconstruction with a wraparound free flap according to the level of amputation. Microsurgery 2000;20:25-31.
22
Figure 1. Comparison of survival and functional outcomes between four types of toe-to-thumb transfers.
Figure 2 M Grant support received from Midcareer Investigator Award in Patient-
Oriented Research (K24 AR053120) from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (to Dr. Kevin C. Chung).
v Speaker has nothing of financial value to disclose
Long-Term Donor Site Morbidity in Free Non-vascularized Toe Phalangeal Transfer
∙ ∙
∙ ∙
∙
Level 4 Evidence
Phalangeal growth distal to the donor phalanx is universally compromised. Metatarsal length proximal to the donor proximal phalanx is radiographically reduced in 48% of cases and metatarsal head width is reduced in all cases. Preoperative counselling should include discussion on long term donor site morbidity and alternative techniques. The authors would recommend attempts to restore the structural integrity of the toes after free phalangeal harvest such as that proposed by Bourke and Kay. The results of surgical procedures performed in childhood on the musculoskeletal system can only be adequately judged with long-term follow-up.
v Lorenzo Garagnani, MD Marc Gibson, MB, BSc Gillian Dawn Smith, FRCS
):105)&4*4 Free non-vascularized toe phalangeal transfer is an established surgical option for reconstruction of hypoplastic digits. Several studies, all with limited numbers and short follow-up, focus on the surgical technique and the outcome in the hand, but barely mention the donor site. It is stated that the donor site defect is usually minimal - this study has specifically tested this hypothesis with review of the donor site after long-term follow-up.
.&5)0%4 This is a retrospective cohort review of 40 children with hypoplastic digits who underwent 126 free non-vascularized toe phalangeal transfers between 1991 and 2007. Mean age at transfer was 40 months (range 7-125 months). Mean postoperative follow-up was 10 years (range 36-228 months). Median follow-up was 114 months (IQR 73-164 months). The Oxford Ankle Foot Questionnaire was administered to patients and families. Clinical review assessed toe length ratio, visible deformity, and stability of the donor toes. Radiographic measurements (n=19 toes) and photographic measurement (n=41 toes) were performed.
3&46-54 93.3% of patients and 88.8% of families interviewed reported variable degrees of dissatisfaction with the donor feet. This study has shown increasing foot deformity with age, with significant aesthetic deterioration. All patients have floppy unstable toes with visible shortening and deformity at long-term follow-up. On radiographs, phalangeal hypoplasia distal to the harvested phalanges was present in 100% of cases, metatarsal shortening in 48% of cases, and metatarsal head hypoplasia in 100% of donor rays. Radiographic and photographic measurement of donor toes length showed inversion of the normal toe length ratio in all donor toes.
PAPER 27 'SJEBZ 4FQUFNCFS t". $MJOJDBM1BQFS4FTTJPO.JDSPTVSHFSZ
A Systematic Review of Outcomes of Toe-to-Thumb Transfers for Isolated Traumatic Thumb Amputation Level 3 Evidence Pao-Yuan Lin, MD Sandeep J. Sebastin, MCh Shimpei Ono, MD, PhD Kevin C. Chung, MD, MS
M
):105)&4*4 We hypothesize that trimmed great toe transfer provides the best functional and aesthetic reconstruction of a thumb amputated distal to the metacarpophalangeal joint when compared to great toe, second toe, and wrap-around great toe transfer techniques (Figure 1).
.&5)0%4 A MEDLINE/ EMBASE and ISI search using “toe-to-thumb transfer combined with thumb injury and reconstruction” as keywords and limited to humans and the English language identified 633 studies. Studies were included in the review if they: (1) present primary data; (2) report 3 or more toe-to-thumb transfers for isolated complete traumatic thumb amputation through the proximal phalanx; (3) present functional outcome data. Additional data extracted from the studies meeting the inclusion criteria included demographic information, donor morbidity, and patient satisfaction.
46.."3:10*/54 ∙ ∙ ∙
There are functional and aesthetic problems with the donor site from free non-vascularized phalangeal transfer. Deformities of all donor toes have been identified at long-term follow-up. Normal toe length ratio is inverted in all donor toes at longterm follow-up.
v Speaker has nothing of financial value to disclose
3&46-54 25 studies representing 450 toe-to-thumb transfers met the inclusion criteria. They included 101 second toe transfers, 196 great toe transfers, 122 wrap-around transfers, and 31 trimmed toe transfers. The mean survival rate was 96.4%. No statistically significant differences could be detected amongst the 4 types
21
of toe-to-thumb transfers with regards to survival or any of the functional outcome parameters [arc of motion (AOM), total active motion (TAM), grip and pinch strength, and static two-point discrimination (2 PD)] (Figure 1).
46.."3:10*/54 ∙
∙
∙ ∙
The traditional teaching is that A great toe makes a great thumb because a great toe transfer results in better motion and superior strength compared to a second toe transfer. This study revealed that all 4 types of toe-to-thumb transfer procedures have predictably high survival rates and found no statistically significant differences in the factors of survival, AOM, TAM, grip and key pinch strength, and static 2-PD. There is no dominant technique that favors its selection based on the best available data from the literature. The selection of the techniques relies on the preference and expertise of the surgeon, and perhaps the patient's perception of the outcomes and donor site trade-offs.
3&'&3&/$&4 1. Morrison WA, O’Brien BM, MacLeod AM. Thumb reconstruction with a free neurovascular wrap-around flap from the big toe. J Hand Surg 1980;5A:575-583. 2. Poppen NK, Norris TR, Buncke HJ, Jr. Evaluation of sensibility and function with microsurgical free tissue transfer of the great toe to the hand for thumb reconstruction. J Hand Surg 1983;8A:516-531. 3. Doi K, Kuwata N, Kawai S. Reconstruction of the thumb with a free wrap-around flap from the big toe and an iliac-bone graft. J Bone Joint Surg 1985;67A:439-445. 4. Tsai TM, McCabe 217 S, Beatty ME. Second toe transfer for thumb reconstruction in multiple digit amputations including thumb and basal joint. Microsurgery 1987;8:146-153. 5. Wei FC, Chen HC, Chuang CC, Chen SH. Microsurgical thumb reconstruction with toe transfer: selection of various techniques. Plast Reconstr Surg 1994;93:345-357. 6. Chung KC, Wei FC. An outcome study of thumb reconstruction using microvascular toe transfer. J Hand Surg 2000;25A:651-658. 7. Woo SH, Kim JS, Seul JH. Immediate toe-to-hand transfer in acute hand injuries: overall results, compared with results for elective cases. Plast Reconstr Surg 2004;113:882-892. 8. Lee CK, Buncke GM. Great toe-to-thumb microvascular transplantation. Clin Plast Surg 2007;34:223-231. 9. Huang D, Wang HG, Wu WZ, Zhang HR, Lin H. Functional and aesthetic results of immediate reconstruction of traumatic thumb defects by toe-to-thumb transplantation. Int Orthop 2010. 10.Lee KS, Park JW, Chung WK. Thumb reconstruction with a wraparound free flap according to the level of amputation. Microsurgery 2000;20:25-31.
22
Figure 1. Comparison of survival and functional outcomes between four types of toe-to-thumb transfers.
Figure 2 M Grant support received from Midcareer Investigator Award in Patient-
Oriented Research (K24 AR053120) from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (to Dr. Kevin C. Chung).
v Speaker has nothing of financial value to disclose