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Thumb Amputations in Children: Classification and Reconstruction by Microsurgical Toe Transfers
SCIENTIFIC ARTICLE
Thumb Amputations in Children: Classification and Reconstruction by Microsurgical Toe Transfers Neil F. Jones, MD,*† James E. Clune, MD‡
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. (J Hand Surg Am. 2018;-(-):1.e1-e10. Copyright Ó 2018 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence IV. Key words Amputation, children, microsurgery, thumb reconstruction, toe transfer.
From the *Department of Orthopaedic Surgery, University of California Irvine Hand Center, Orange; the †Shriners Hospital of Los Angeles, Los Angeles, CA; and the ‡Department of Plastic Surgery, Yale School of Medicine, New Haven, CT.
Corresponding author: Neil F. Jones MD, Department of Orthopaedic Surgery, University of California Irvine Hand Center, 101 The City Dr. South, Pavilion III, Building 29A, Orange, CA 92868; e-mail: [email protected].
Received for publication December 25, 2017; accepted in revised form August 22, 2018.
0363-5023/18/---0001$36.00/0 https://doi.org/10.1016/j.jhsa.2018.08.013
No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.
Ó 2018 ASSH
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Published by Elsevier, Inc. All rights reserved.
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OE-TO-THUMB TRANSFER HAS BECOME AN accepted practice for reconstruction after traumatic thumb amputation in the adult population.1e3 Perhaps because traumatic digital amputations are rare in children, surgical reconstruction using toe-to-hand transfers have only been reported infrequently.4e9 However, indications and outcomes for toe-to-hand reconstruction of congenital hand differences in children have been reported more frequently. The options for thumb reconstruction in children include on-top plasty, osteoplastic reconstruction, distraction lengthening,10e14 pollicization of a normal or injured finger,15e23 and microsurgical toe-to-thumb transfers. However, parents may be reluctant to consider a complex microsurgical reconstructive option that may result in failure, subsequently leaving their child not only with the same thumb amputation but also now with a missing toe. Hand surgeons may also be reticent to propose or embark on such a technically challenging option in a child and still frequently rely on distraction lengthening or pollicization to reconstruct the amputated thumb. The aim of this study was to demonstrate that microsurgical toe-to-thumb transfer after traumatic amputation is a very reliable technique for thumb reconstruction in children because it provides length, opposition, sensation, growth, and cosmetic replacement for what has been lost.
TABLE 1. Age (y)
Number of Children
<5
6
6e10
7
11e14
2
15e17
4
Mean
8.2 y
proximal than the base of the metacarpal, but were considered for pollicization. Interestingly, no parents have ever chosen pollicization of a normal index finger for posttraumatic reconstruction of their child’s thumb during the senior author’s (N.F.J.) career. Children were only considered candidates for distraction lengthening if there was at least 2 cm of thumb metacarpal remaining. Only those children whose parents elected to undergo toe-to-thumb transfer were included in this study. There were 19 children with 21 thumb amputations— 15 boys and 4 girls between the ages of 2 and 17 years old (mean, 8.2 years). Six children were younger than 5 years old; 7 children were between 6 and 10 years old; 2 children were between 11 and 14 years old; and 4 children were between 15 and 17 years old (Table 1). Only 1 of the 4 children aged 15 to 17 years showed evidence of skeletal maturity but was considered as a child because he had not reached the age of legal consent. Since 1995, we have documented amputations of the thumb and fingers in both adults and children based on a classification system developed for congenital absent digits (Fig. 1).24 An isolated thumb amputation is classified as R1 (the thumb being the first radial digit). Amputation of the thumb and index finger is classified as R2; amputation of the thumb, index, and middle fingers is classified as R3; amputation of the thumb, index, middle, and ring fingers is classified as R4. Finally, amputation of the thumb and all 4 fingers is classified as R5 and describes a metacarpal hand. The classification system can be further refined by describing the level of amputation of the thumb as w—from the radio-carpal joint to the CMC joint; m—from distal to the CMC joint to just distal to the metacarpophalangeal (MCP) joint; and p—from distal to the MCP joint to the tip of the thumb. There were 10 isolated thumb amputations (R1 classification) and 11 combined thumb and multiple finger amputations—R2(1), R3(3), R4(1), and R5(6) (Fig. 1). Two children had bilateral thumb amputations due to burns. Of the unilateral thumb amputations, 9 were left thumbs and 8 were right thumbs.
MATERIALS AND METHODS Institutional review board approval from Shriners Hospital for Children, Los Angeles, CA and the University of California, Irvine, CA, and parental consent for publication were obtained. During a consultation with the senior author (N.F.J.), the parents of all children who had sustained a thumb amputation between 1998 and 2015 were shown preoperative and postoperative photographs and videos of children who had undergone reconstruction by either distraction lengthening, pollicization, or toe-to-thumb transfer and were provided with an opportunity to see a child who had undergone 1 of these reconstructions and speak with the parents face-to-face in the clinic or through a telephone conversation. However, the level of the child’s thumb amputation did influence which of the 3 potential reconstructive techniques were considered by the surgeon. Thumb amputations between 1 cm distal to the carpometacarpal (CMC) joint and the middiaphysis of the proximal phalanx were considered for a toe transfer. Distraction lengthening and toe transfers were not considered for thumb amputations more J Hand Surg Am.
Age Distribution
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FIGURE 1: Classification of thumb amputations.
Three thumbs were amputated just distal to the CMC joint, 5 through the metacarpal head or MCP joint, 8 through the base of the proximal phalanx, and 5 through the diaphysis and head of the proximal phalanx. Eight thumbs would be classified at the m level and 13 at the p level. Three children had previously undergone soft tissue coverage with a pedicled groin flap (2) or a reverse radial forearm flap (1). Parents and 13 children who were 14 years or older completed the Pediatric Outcomes Data Collection Instrument (PODCI) a minimum of 2 years after the toe-to-thumb transfer surgery. Only children who were 14 years or older were considered to be fully capable of understanding and completing the PODCI.
second toe is usually the only option. If the second toe was transferred, the osteotomy was always made at the metaphyseal flare of the metatarsal and excess bone was removed from the metatarsal as necessary. For a great toe transfer, an osteotomy was made at the base of the proximal phalanx or disarticulation was performed through the metatarsophalangeal joint, but osteotomies more proximally through the metatarsal head are to be avoided because of gait disturbances. After transfer to the hand, osteosynthesis was achieved with 90-90 intraosseous wiring technique. An end-to-end arterial anastomosis was performed to the radial artery in the anatomical snuff box and an end-to-end venous anastomosis was performed to a dorsal vein. The fibular and tibial digital nerves of the toe transfer were coapted to the radial and ulnar digital nerves of the amputated thumb and the deep peroneal nerve was coapted to a branch of the superficial radial nerve. In those children without a proximal remnant of the flexor pollicis longus tendon, the flexor digitorum sublimis tendon from the ring finger was transferred (2). In those children without a proximal remnant of the extensor pollicis longus tendon, the extensor indicis proprius tendon or an extensor tendon from an adjacent amputated finger was transferred (3). All children were given dextran 40 after completion of the arterial anastomosis and remained on a dextran infusion (0.36 mL/kg/h) for 5 days after surgery. In our experience, dextran has a lower incidence of hematoma and postoperative bleeding than heparin. Children younger than 10 years of age were immobilized in a long-arm sugar tong orthosis with a plaster hood fashioned above the toe transfer to protect it from inadvertent trauma. Postoperative monitoring consisted of continuous pulse oximetry of the transferred toe and comparison with a normal contralateral finger.26
Surgical technique The ipsilateral great toe or the contralateral second toe was selected as the donor. Angiograms of the foot were not obtained, but Doppler evaluation of the foot was performed to determine whether the dorsal or plantar arterial system was dominant. The dominant vascular supply to the selected toe was defined in the web space after transection of the intermetatarsal ligament. If the first dorsal metatarsal artery was dominant, it was traced back to the dorsalis pedis artery. If the first plantar metatarsal artery (FPMA) was dominant, either the ipsilateral saphenous vein was harvested as a separate vein graft or the saphenous vein was dissected above the ankle and temporarily anastomosed on a back table to the FPMA as a temporary arteriovenous loop.25 Although the level of the thumb amputation does influence the choice of either a second toe or a great toe, it does not really influence the level at which the osteotomy of the donor toe is made. Thumb amputations proximal to the MCP joint usually preclude the choice of a great toe transfer and a J Hand Surg Am.
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FIGURE 2: Avulsion injury of the right thumb of a young girl after failed replantation, resulting in an isolated thumb amputation (R1m) at the level of the midproximal phalanx.
RESULTS Twenty-one toes were transferred (Table 1) in 19 children—14 second toe transfers (Figs. 2e7) and 7 great toe transfers (3 great toe [Figs. 8e11], 2 trimmed [Figs. 12e15], and 2 Morrison wraparound variations). One teenager with bilateral thumb amputations due to electrical burns underwent simultaneous Morrison wraparound great toeeto-thumb reconstructions semiemergently at the time of radical debridement. The first dorsal metatarsal artery was the dominant blood supply for 14 toe transfers. The first plantar metatarsal artery was the dominant blood supply for 7 toe transfers and required lengthening with a vein graft (Table 2). The youngest child with a dominant FPMA circulation was 3 years old. Two children underwent a reverse radial forearm flap simultaneously with their toe transfer to provide both soft tissue coverage and arterial inflow to the toe transfer.27 No postoperative reexplorations of the microsurgical anastomoses were required, and all 21 toe transfers survived completely. All children required either a fullthickness skin graft from the groin or a split-thickness skin graft from the thigh to achieve tension-free closure of the recipient hand. No wound complications were identified in either the donor foot or the skin graft donor site. Hospital stay ranged between 5 and 7 days. Follow-up ranged from 2 and 18 years. No children reported any difficulty with ambulation and all use regular shoes (Figs. 7, 15). J Hand Surg Am.
FIGURE 3: Immediate radiograph shows 90-90 intraosseous wiring of the proximal phalanx of a second toe transfer to the proximal phalanx of the thumb and temporary K-wire fixation of the distal interphalangeal joint in extension to prevent a flexion contracture.
All children developed active pinch and grasp and achieved Kapandji scores of 5 with opposition of the toe-to-thumb transfer to the tip of the remaining small finger (Fig. 4) or to the tip of a second toe transfer in the 3 children with 4 R5 metacarpal hands in whom an opposable digit on the ulnar side of the hand was reconstructed with another second toe transfer. All children obtained subjective sensibility in the transferred toe equal to the contralateral thumb or an adjacent finger with 2-point discrimination of 5 to 7 mm. Comparison of the length of the 3 phalanges in a second toe transfer and the 2 phalanges in a great toe transfer on posteroanterior radiographs demonstrated radiological evidence of serial growth and comparable r
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FIGURE 4: Second toe transfer 1 year after surgery shows opposition of the toe-to-thumb transfer to the little finger (Kapandji score 5).
FIGURE 6: Left second toe-to-thumb transfer shows opposition to the little finger (Kapandji score 5) 1 year after surgery.
joint of the transferred second toe in extension for 3 to 6 weeks after surgery (Fig. 3), 3 children still developed flexion contractures of the distal interphalangeal joint and underwent arthrodesis. Two children underwent arthrodesis of the metatarsophalangeal joint of the transferred toe to correct a hyperextension deformity. Four hands of 3 children with R5 metacarpal hands underwent secondary reconstruction with a further 6 toes transferred to the ulnar aspect of their hands to provide 1 or 2 opposable digits. One child with an R5 metacarpal hand is considering another second toe transfer into the ulnar side of the hand to provide an opposable digit and 1 child with an R5 metacarpal hand with amputation of all the fingers distal to the proximal interphalangeal joints did not require any further reconstruction. From the PODCI, all parents reported that the function of their child’s hand/s had improved after the toe-to-thumb transfer/s and the parents of the 10 children with an isolated R1 hand were very satisfied with the appearance of their child’s hand. All parents were happy to accept the appearance of the donor site in the foot in order to improve their child’s hand function and social integration.
FIGURE 5: Amputation of the right thumb and index and middle fingers (R3 classification) and partial amputation of the ring finger in a 9-year-old boy due to an explosion, with primary coverage with a groin flap.
growth of the transferred toe with the remaining contralateral nontransferred second toe or great toe in 16 toe transfers. One child required flexor tenolysis of the transferred toe-to-thumb transfer prior to achieving active pinch. Despite pinning of the distal interphalangeal J Hand Surg Am.
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DISCUSSION Toe-to-thumb transfer for posttraumatic reconstruction is more frequently reported in adults than in the pediatric age group. Hand surgeons frequently recommend reconstruction by distraction lengthening r
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FIGURE 8: Amputation of all 5 digits of the left hand (R5m classification) in an 8-year-old boy due to burns.
of 6 thumb amputations, 1 of whom was a 12-yearold child, out of a series of 19 ray lengthenings with an average lengthening of 20 mm. Distraction lengthening requires a lengthy commitment and may not be well tolerated in a young child. If bony consolidation does not occur spontaneously, or if the parents do not accept allograft bone, secondary bone grafting of the resultant defect is frequently required and even a third-stage z-plasty procedure to deepen the thumb-index finger web space may be necessary. Although it results in a stable post, it does not provide much mobility, other than at the CMC joint and is much less aesthetic than a toe transfer. Tanzer and Littler15 and Littler16 first described pollicization by transfer of the index finger on its neurovascular pedicles. The middle, ring, and little fingers have been less frequently described for pollicization. Although pollicization was originally reported for posttraumatic thumb reconstruction, Buck-Gramcko17 revolutionized the reconstruction of children born with congenital thumb aplasia and hypoplasia by pollicization of the index finger. Posttraumatic thumb reconstruction in children by pollicization is rarely described in the literature.18e22 Foucher et al23 reported 27 pollicizations using the remnants of mutilated fingers, 78% of whom were described as having achieved a good or fair result. Weinzweig et al22 described pollicization of the stump of an
FIGURE 7: Donor site of the left second toe transfer 1 year after surgery.
or by pollicization of the index finger for posttraumatic reconstruction of the thumb in children, rather than microsurgical reconstruction. Microsurgery in children is perceived as extremely challenging because the pediatric vasculature is small and prone to vasospasm and postoperative monitoring is difficult. Matev10 first described thumb reconstruction by distraction lengthening of the metacarpal and stated that the prerequisites were an intact metacarpal, or at least two-thirds of the metacarpal, as well as satisfactory skin coverage of the thumb amputation stump. He initially reported distraction lengthening of 6 children between 10 and 14 years old who achieved lengthening of 2.5 to 3.8 cm after an average distraction of 35 days and spontaneous consolidation within 3 months. In a follow-up study of 8 patients aged 16 to 19 years, lengthening of 2 to 4 cm was achieved after distraction of 30 days and completion of the bony consolidation within 4.5 months.11,12 Kessler et al13 extended the technique of distraction lengthening to reconstruction of digits other than the thumb. Salom et al14 reported distraction lengthening J Hand Surg Am.
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FIGURE 11: Left great toeeto-thumb transfer 1 year after surgery.
FIGURE 9: Preoperative markings of a left great toe transfer.
FIGURE 12: Amputation of the left thumb through the MCP joint (R1m classification) in a 10-year-old boy.
reported 9 thumb reconstructions in 8 children by advancement pollicization of the remnant of the index finger onto the remaining proximal thumb metacarpal stump resulting in power pinch ranging from 2 to 10 lbs. Similarly, Ward et al29 described reconstruction of 15 thumb amputations at the level of the MCP joint due to burns in 11 children between 3 and 16 years of age who underwent pollicization of the index finger remnant. Seventy-four percent achieved good or excellent results in terms of pinch, grasp, and opposition, and 94% demonstrated overall
FIGURE 10: Left great toe transfer and associated anatomical markings. DPA, digital plantar artery; DPN, deep peroneal nerve; EHL, extensor hallucis longus; FHL, flexor hallucis longus; LDN, lateral plantar digital nerve; MDN, medial digital plantar nerve; SPN, superficial peroneal nerve; V, vein.
injured middle finger to reconstruct the thumb of a 17-year-old boy. Thumb reconstruction of the severely burned hands of children is especially challenging. May et al28 J Hand Surg Am.
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FIGURE 13: “Trimmed” left great toe transfer.
FIGURE 15: Donor site of the left foot 1 year after harvesting a “trimmed” great toe transfer.
TABLE 2.
Dominant Arterial Supply
FDMA
14 toes
FPMA þ vein graft
7 toes*
FDMA, first dorsal metatarsal artery. *Youngest patient with FPMA dominant anatomy was 3 years old.
Cooney and Wood4 described 5 children aged 3 to 9 years with posttraumatic thumb amputations who underwent reconstruction with second toe transfers. Shvedovchenko5 reported transferring toes to reconstruct fingers and thumbs in 17 children after traumatic amputations. From a series of 66 toe transfers in 40 children, Kay and Wiberg6 described 5 children between 3 and 10 years of age who underwent posttraumatic thumb reconstruction using a second toe in 4 children and a wraparound great toe in one child. Wei et al7 specifically described the reconstruction of 13 pediatric thumb amputations using toe transfers in 1997 with a follow-up report in 2003.8 Wolff and Posso9 in 2014 reported the results of second toe transfers for reconstruction of 9 children younger than 5 years after traumatic thumb amputation. Because thumb amputations in children are so rare, the small case series to date have not been adequate to define toe-to-thumb transfers as the gold standard for reconstruction of children’s thumbs after traumatic amputation. There is only 1 study comparing the functional outcomes of pollicizations with toe-to-
FIGURE 14: Appearance and opposition of the “trimmed” great toeeto-left thumb transfer to the little finger (Kapandji score 5).
improvement in hand function. There are very few reports of pollicization of a normal index finger for posttraumatic reconstruction of an amputated thumb in children, presumably because parents are reluctant to accept pollicization because this sacrifices a normal adjacent finger and perhaps the hand is then aesthetically inferior to a great toe transfer or the trimmed toe or Morrison wraparound variations. J Hand Surg Am.
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thumb transfers and no studies comparing the results of distraction lengthening with toe-to-thumb transfers. Michon et al30 compared the functional results of 33 pollicizations and 21 toe-to-thumb transfers in 6 categories—sensibility, mobility, strength, appearance, pinch, and grasp. For isolated thumb amputations (equivalent to the R1 classification), pollicizations were associated with better sensation, mobility, and pinch, whereas toe-to-thumb transfers provided better strength and grasp. For thumb and multiple finger amputations (corresponding to the R2-R4 classification), as well as amputations of the thumb in metacarpal hands (corresponding to the R5 classification), toe-to-thumb transfers provided superior outcomes in all 6 categories. Of the 21 toe-to-thumb transfers in our series, great toe transfers provided better function and appearance than second toe transfers. Selection of the donor toe, either the great toe or the second toe, was discussed extensively with the parents prior to surgery; however, many parents were reticent to accept the perceived cosmetic deformity of the foot after harvest of the great toe and chose the second toe. Kay and Bellew et al31,32 reviewed the psychosocial outcomes of 37 children who had undergone toe-to-hand reconstruction, including 5 children who had sustained traumatic amputations. Both the children and their parents reported a high level of satisfaction in terms of function, appearance, donor site, psychosocial well-being, and the reaction of others, with the children tending to be more positive than their parents. In a follow-up study of 25 children 10 or more years after toe-to-hand transfer, both the children and their parents continued to express the same high level of satisfaction, but at the 10-year stage, the positivity of the parental responses was equal to the children’s.33 Kaplan and Jones34 evaluated 10 adolescents who had previously undergone toe-to-hand transfers and 15 parents using the PODCI. Six dimensions were evaluated in parents of pediatric and adolescent patients and adolescent self-reports resulting in 18 groups. There were no significant differences between the toe transfer children and the normal pediatric population in 13 of 18 groups (72%). Adolescent patient scores were lower than normal in upper extremity function and transfer/ mobility dimensions, but adolescents self-reported higher scores in sports/physical function and happiness categories compared with their parents’ reported outcomes. Our series demonstrates that toe-to-thumb transfers in children after trauma are very reliable with no failures and no reexplorations in 21 transfers and with excellent long-term functional and psychosocial J Hand Surg Am.
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outcomes. In our series, no children have developed any gait disturbances, including the 2 children who underwent bilateral great toeeto-thumb transfers. All children regained pinch and grasp function and subjective sensation similar to the contralateral thumb or an adjacent finger. Children may have some difficulty cooperating with a therapist during the initial rehabilitation period, but it is generally assumed that children develop fewer tendon adhesions than adults. Toe-to-thumb transfer has become the accepted standard for reconstruction in adults after thumb amputation and based on this and previous series should be similarly offered to the parents of all children who have sustained thumb amputations. Toe-to-thumb transfer is a single-stage procedure that provides greater length and maintains growth potential compared with distraction lengthening. It also preserves all 4 fingers or the remaining fingers in contrast to pollicization. Second toeeto-thumb transfers are preferred for younger children because of better growth potential and an inconspicuous donor site, but great toeeto-thumb transfers become more favored for older children because of the better cosmetic appearance and to provide a larger sensate area in combined thumb and multiple finger amputations. It is the authors’ opinion that continuing to rely on distraction lengthening or pollicization, even for isolated R1 thumb amputations, can no longer be justified given the reliability and excellent results provided by performing a toe-to-thumb transfer in a child, and becomes even less indicated for R3-R5 thumb amputations associated with multiple finger amputations. REFERENCES 1. Cobbett JR. Free digital transfer. Report of a case of transfer of a great toe to replace an amputated thumb. J Bone Joint Surg Br. 1969;51(4):677e679. 2. Buncke GM, Buncke HJ, Lee CK. Great toeeto-thumb microvascular transplantation after traumatic amputation. Hand Clin. 2007;23(1):105e115. 3. 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(4):693e700. 4. Cooney WP 3rd, Wood MB. Microvascular reconstruction of congenital anomalies and post-traumatic lesions in children. Hand Clin. 1992;8(1):131e146. 5. Shvedovchenko IV. Toe-to-hand transfers in children. Ann Plast Surg. 1993;31(3):251e254. 6. Kay SP, Wiberg M. Toe to hand transfer in children. Part 1: technical aspects. J Hand Surg Br. 1996;21(6):723e734. 7. Wei FC, El-Gammal TA, Chen HC, Chuang DC, Chiang YC, Chen SH. Toe-to-hand transfer in children and adolescents. Plast Reconstr Surg. 1997;100(3):605e609. 8. Wei FC, Mardini S. Reevaluation of the technique of toe-to-hand transfer for traumatic digital amputations in children and adolescents. Plast Reconstr Surg. 2003;112(7):1870e1874.
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23. Foucher G, Navarro R, Medina J, Allieu Y. Pollicization, remains of the past or current operations [in French]. Bull Acad Nat Med. 2000;184(6):1241e1253. 24. Jones NF, Kaplan J. A new documentation system for congenital absent digits. Hand (N Y). 2012;7(4):391e399. 25. Brown EE, Chang WT, Jones NF. Temporary arteriovenous loop between the saphenous vein and first plantar metatarsal artery in toe-to-hand transfers. J Hand Surg Am. 2006;31(9): 1543e1545. 26. Jones NF, Gupta R. Postoperative monitoring of pediatric toe-to-hand transfers with differential pulse oximetry. J Hand Surg Am. 2001;26(3):525e529. 27. Kim JH, Yoon AP, Jones NF. Reverse radial forearm flap to provide arterial inflow to a toe transfer. Hand (N Y). 2017;12(2):154e161. 28. May JW, Donelan MB, Toth BA, Wall J. Thumb reconstruction in the burned hand by advancement pollicization of the second ray remnant. J Hand Surg Am. 1984;9(4):484e489. 29. Ward JW, Pensler JM, Parry SW. Pollicization for thumb reconstruction in severe pediatric hand burns. Plast Reconstr Surg. 1985;76(6):927e932. 30. Michon J, Merle M, Bouchon Y, Foucher G. Functional comparison between pollicization and toe-to-hand transfer for thumb reconstruction. J Reconstr Microsurg. 1984;1(2):103e110. 31. Kay SP, Wiberg M, Bellew M, Webb F. Toe to hand transfer in children. Part 2: functional and psychological aspects. J Hand Surg Br. 1996;21(6):735e745. 32. Bellew M, Kay SP. Psychological aspects of toe to hand transfer in children. Comparison of children and their parents. J Hand Surg Br. 1999;24(6):712e718. 33. Bellew M, Haworth J, Kay SP. Toe transfer in children: ten year follow up of psychosocial aspects. J Plast Reconstr Aesthet Surg. 2011;64(6):766e775. 34. Kaplan JD, Jones NF. Outcome measures of microsurgical toe transfers for reconstruction of congenital and traumatic hand anomalies. J Pediatr Orthop. 2014;34(3):362e368.
9. Wolff G, Posso C. Second-toe transfer for traumatic thumb amputation in children under 5 years: bone and soft-tissue growth. Tech Hand Up Extrem Surg. 2014;18(4):175e180. 10. Matev IB. Thumb reconstruction in children through metacarpal lengthening. Plast Reconstr Surg. 1979;64(5):665e669. 11. Matev IB. Thumb reconstruction through metacarpal bone lengthening. J Hand Surg Am. 1980;5(5):482e487. 12. Matev IB. The bone-lengthening method in hand reconstruction: twenty years’ experience. J Hand Surg Am. 1989;14(2 Pt 2):376e378. 13. Kessler I, Hecht O, Baruch A. Distraction-lengthening of digital rays in the management of the injured hand. J Bone Joint Surg Am. 1979;61(1):83e87. 14. Salom M, Aroca JE, Chover V, Alonso R, Vilar R. Distractionlengthening of digital rays using a small external fixator. J Hand Surg Br. 1998;23(6):781e784. 15. Tanzer RC, Littler JW. Reconstruction of the thumb by transposition of an adjacent digit. Plast Reconstr Surg (1946). 1948;3(5):533e547. 16. Littler JW. The neurovascular pedicle method of digital transposition for reconstruction of the thumb. Plast Reconstr Surg. 1953;12(5): 303e319. 17. Buck-Gramcko D. Pollicization of the index finger: method and results in aplasia and hypoplasia of the thumb. J Bone Joint Surg Am. 1971;53(8):1605e1617. 18. Stern PJ, Lister GD. Pollicization after traumatic amputation of the thumb. Clin Orthop Relat Res. 1981;155:85e94. 19. Reid DAC. Thumb reconstruction by pollicization in mutilating injuries of the hand. In: Reid DAC, Tubiana R, eds. Mutilating Injuries of the Hand. Edinburgh: Churchill Livingstone; 1984:141e156. 20. Dijkstra R. Thumb reconstruction in the severely damaged hand using finger remnants. Neth J Surg. 1989;41(1):11e14. 21. Brunelli GA, Brunelli GR. Reconstruction of traumatic absence of the thumb in the adult by pollicization. Hand Clin. 1992;8(1):41e55. 22. Weinzweig N, Chen L, Chen ZW. Pollicization of the mutilated hand by transposition of middle and ring finger remnants. Ann Plast Surg. 1995;34(5):523e529.
J Hand Surg Am.
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Thumb Amputations in Children: Classification and Reconstruction by Microsurgical Toe Transfers Neil F. Jones, MD,*† James E. Clune, MD‡
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. (J Hand Surg Am. 2018;-(-):1.e1-e10. Copyright Ó 2018 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence IV. Key words Amputation, children, microsurgery, thumb reconstruction, toe transfer.
From the *Department of Orthopaedic Surgery, University of California Irvine Hand Center, Orange; the †Shriners Hospital of Los Angeles, Los Angeles, CA; and the ‡Department of Plastic Surgery, Yale School of Medicine, New Haven, CT.
Corresponding author: Neil F. Jones MD, Department of Orthopaedic Surgery, University of California Irvine Hand Center, 101 The City Dr. South, Pavilion III, Building 29A, Orange, CA 92868; e-mail: [email protected].
Received for publication December 25, 2017; accepted in revised form August 22, 2018.
0363-5023/18/---0001$36.00/0 https://doi.org/10.1016/j.jhsa.2018.08.013
No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.
Ó 2018 ASSH
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OE-TO-THUMB TRANSFER HAS BECOME AN accepted practice for reconstruction after traumatic thumb amputation in the adult population.1e3 Perhaps because traumatic digital amputations are rare in children, surgical reconstruction using toe-to-hand transfers have only been reported infrequently.4e9 However, indications and outcomes for toe-to-hand reconstruction of congenital hand differences in children have been reported more frequently. The options for thumb reconstruction in children include on-top plasty, osteoplastic reconstruction, distraction lengthening,10e14 pollicization of a normal or injured finger,15e23 and microsurgical toe-to-thumb transfers. However, parents may be reluctant to consider a complex microsurgical reconstructive option that may result in failure, subsequently leaving their child not only with the same thumb amputation but also now with a missing toe. Hand surgeons may also be reticent to propose or embark on such a technically challenging option in a child and still frequently rely on distraction lengthening or pollicization to reconstruct the amputated thumb. The aim of this study was to demonstrate that microsurgical toe-to-thumb transfer after traumatic amputation is a very reliable technique for thumb reconstruction in children because it provides length, opposition, sensation, growth, and cosmetic replacement for what has been lost.
TABLE 1. Age (y)
Number of Children
<5
6
6e10
7
11e14
2
15e17
4
Mean
8.2 y
proximal than the base of the metacarpal, but were considered for pollicization. Interestingly, no parents have ever chosen pollicization of a normal index finger for posttraumatic reconstruction of their child’s thumb during the senior author’s (N.F.J.) career. Children were only considered candidates for distraction lengthening if there was at least 2 cm of thumb metacarpal remaining. Only those children whose parents elected to undergo toe-to-thumb transfer were included in this study. There were 19 children with 21 thumb amputations— 15 boys and 4 girls between the ages of 2 and 17 years old (mean, 8.2 years). Six children were younger than 5 years old; 7 children were between 6 and 10 years old; 2 children were between 11 and 14 years old; and 4 children were between 15 and 17 years old (Table 1). Only 1 of the 4 children aged 15 to 17 years showed evidence of skeletal maturity but was considered as a child because he had not reached the age of legal consent. Since 1995, we have documented amputations of the thumb and fingers in both adults and children based on a classification system developed for congenital absent digits (Fig. 1).24 An isolated thumb amputation is classified as R1 (the thumb being the first radial digit). Amputation of the thumb and index finger is classified as R2; amputation of the thumb, index, and middle fingers is classified as R3; amputation of the thumb, index, middle, and ring fingers is classified as R4. Finally, amputation of the thumb and all 4 fingers is classified as R5 and describes a metacarpal hand. The classification system can be further refined by describing the level of amputation of the thumb as w—from the radio-carpal joint to the CMC joint; m—from distal to the CMC joint to just distal to the metacarpophalangeal (MCP) joint; and p—from distal to the MCP joint to the tip of the thumb. There were 10 isolated thumb amputations (R1 classification) and 11 combined thumb and multiple finger amputations—R2(1), R3(3), R4(1), and R5(6) (Fig. 1). Two children had bilateral thumb amputations due to burns. Of the unilateral thumb amputations, 9 were left thumbs and 8 were right thumbs.
MATERIALS AND METHODS Institutional review board approval from Shriners Hospital for Children, Los Angeles, CA and the University of California, Irvine, CA, and parental consent for publication were obtained. During a consultation with the senior author (N.F.J.), the parents of all children who had sustained a thumb amputation between 1998 and 2015 were shown preoperative and postoperative photographs and videos of children who had undergone reconstruction by either distraction lengthening, pollicization, or toe-to-thumb transfer and were provided with an opportunity to see a child who had undergone 1 of these reconstructions and speak with the parents face-to-face in the clinic or through a telephone conversation. However, the level of the child’s thumb amputation did influence which of the 3 potential reconstructive techniques were considered by the surgeon. Thumb amputations between 1 cm distal to the carpometacarpal (CMC) joint and the middiaphysis of the proximal phalanx were considered for a toe transfer. Distraction lengthening and toe transfers were not considered for thumb amputations more J Hand Surg Am.
Age Distribution
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FIGURE 1: Classification of thumb amputations.
Three thumbs were amputated just distal to the CMC joint, 5 through the metacarpal head or MCP joint, 8 through the base of the proximal phalanx, and 5 through the diaphysis and head of the proximal phalanx. Eight thumbs would be classified at the m level and 13 at the p level. Three children had previously undergone soft tissue coverage with a pedicled groin flap (2) or a reverse radial forearm flap (1). Parents and 13 children who were 14 years or older completed the Pediatric Outcomes Data Collection Instrument (PODCI) a minimum of 2 years after the toe-to-thumb transfer surgery. Only children who were 14 years or older were considered to be fully capable of understanding and completing the PODCI.
second toe is usually the only option. If the second toe was transferred, the osteotomy was always made at the metaphyseal flare of the metatarsal and excess bone was removed from the metatarsal as necessary. For a great toe transfer, an osteotomy was made at the base of the proximal phalanx or disarticulation was performed through the metatarsophalangeal joint, but osteotomies more proximally through the metatarsal head are to be avoided because of gait disturbances. After transfer to the hand, osteosynthesis was achieved with 90-90 intraosseous wiring technique. An end-to-end arterial anastomosis was performed to the radial artery in the anatomical snuff box and an end-to-end venous anastomosis was performed to a dorsal vein. The fibular and tibial digital nerves of the toe transfer were coapted to the radial and ulnar digital nerves of the amputated thumb and the deep peroneal nerve was coapted to a branch of the superficial radial nerve. In those children without a proximal remnant of the flexor pollicis longus tendon, the flexor digitorum sublimis tendon from the ring finger was transferred (2). In those children without a proximal remnant of the extensor pollicis longus tendon, the extensor indicis proprius tendon or an extensor tendon from an adjacent amputated finger was transferred (3). All children were given dextran 40 after completion of the arterial anastomosis and remained on a dextran infusion (0.36 mL/kg/h) for 5 days after surgery. In our experience, dextran has a lower incidence of hematoma and postoperative bleeding than heparin. Children younger than 10 years of age were immobilized in a long-arm sugar tong orthosis with a plaster hood fashioned above the toe transfer to protect it from inadvertent trauma. Postoperative monitoring consisted of continuous pulse oximetry of the transferred toe and comparison with a normal contralateral finger.26
Surgical technique The ipsilateral great toe or the contralateral second toe was selected as the donor. Angiograms of the foot were not obtained, but Doppler evaluation of the foot was performed to determine whether the dorsal or plantar arterial system was dominant. The dominant vascular supply to the selected toe was defined in the web space after transection of the intermetatarsal ligament. If the first dorsal metatarsal artery was dominant, it was traced back to the dorsalis pedis artery. If the first plantar metatarsal artery (FPMA) was dominant, either the ipsilateral saphenous vein was harvested as a separate vein graft or the saphenous vein was dissected above the ankle and temporarily anastomosed on a back table to the FPMA as a temporary arteriovenous loop.25 Although the level of the thumb amputation does influence the choice of either a second toe or a great toe, it does not really influence the level at which the osteotomy of the donor toe is made. Thumb amputations proximal to the MCP joint usually preclude the choice of a great toe transfer and a J Hand Surg Am.
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FIGURE 2: Avulsion injury of the right thumb of a young girl after failed replantation, resulting in an isolated thumb amputation (R1m) at the level of the midproximal phalanx.
RESULTS Twenty-one toes were transferred (Table 1) in 19 children—14 second toe transfers (Figs. 2e7) and 7 great toe transfers (3 great toe [Figs. 8e11], 2 trimmed [Figs. 12e15], and 2 Morrison wraparound variations). One teenager with bilateral thumb amputations due to electrical burns underwent simultaneous Morrison wraparound great toeeto-thumb reconstructions semiemergently at the time of radical debridement. The first dorsal metatarsal artery was the dominant blood supply for 14 toe transfers. The first plantar metatarsal artery was the dominant blood supply for 7 toe transfers and required lengthening with a vein graft (Table 2). The youngest child with a dominant FPMA circulation was 3 years old. Two children underwent a reverse radial forearm flap simultaneously with their toe transfer to provide both soft tissue coverage and arterial inflow to the toe transfer.27 No postoperative reexplorations of the microsurgical anastomoses were required, and all 21 toe transfers survived completely. All children required either a fullthickness skin graft from the groin or a split-thickness skin graft from the thigh to achieve tension-free closure of the recipient hand. No wound complications were identified in either the donor foot or the skin graft donor site. Hospital stay ranged between 5 and 7 days. Follow-up ranged from 2 and 18 years. No children reported any difficulty with ambulation and all use regular shoes (Figs. 7, 15). J Hand Surg Am.
FIGURE 3: Immediate radiograph shows 90-90 intraosseous wiring of the proximal phalanx of a second toe transfer to the proximal phalanx of the thumb and temporary K-wire fixation of the distal interphalangeal joint in extension to prevent a flexion contracture.
All children developed active pinch and grasp and achieved Kapandji scores of 5 with opposition of the toe-to-thumb transfer to the tip of the remaining small finger (Fig. 4) or to the tip of a second toe transfer in the 3 children with 4 R5 metacarpal hands in whom an opposable digit on the ulnar side of the hand was reconstructed with another second toe transfer. All children obtained subjective sensibility in the transferred toe equal to the contralateral thumb or an adjacent finger with 2-point discrimination of 5 to 7 mm. Comparison of the length of the 3 phalanges in a second toe transfer and the 2 phalanges in a great toe transfer on posteroanterior radiographs demonstrated radiological evidence of serial growth and comparable r
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FIGURE 4: Second toe transfer 1 year after surgery shows opposition of the toe-to-thumb transfer to the little finger (Kapandji score 5).
FIGURE 6: Left second toe-to-thumb transfer shows opposition to the little finger (Kapandji score 5) 1 year after surgery.
joint of the transferred second toe in extension for 3 to 6 weeks after surgery (Fig. 3), 3 children still developed flexion contractures of the distal interphalangeal joint and underwent arthrodesis. Two children underwent arthrodesis of the metatarsophalangeal joint of the transferred toe to correct a hyperextension deformity. Four hands of 3 children with R5 metacarpal hands underwent secondary reconstruction with a further 6 toes transferred to the ulnar aspect of their hands to provide 1 or 2 opposable digits. One child with an R5 metacarpal hand is considering another second toe transfer into the ulnar side of the hand to provide an opposable digit and 1 child with an R5 metacarpal hand with amputation of all the fingers distal to the proximal interphalangeal joints did not require any further reconstruction. From the PODCI, all parents reported that the function of their child’s hand/s had improved after the toe-to-thumb transfer/s and the parents of the 10 children with an isolated R1 hand were very satisfied with the appearance of their child’s hand. All parents were happy to accept the appearance of the donor site in the foot in order to improve their child’s hand function and social integration.
FIGURE 5: Amputation of the right thumb and index and middle fingers (R3 classification) and partial amputation of the ring finger in a 9-year-old boy due to an explosion, with primary coverage with a groin flap.
growth of the transferred toe with the remaining contralateral nontransferred second toe or great toe in 16 toe transfers. One child required flexor tenolysis of the transferred toe-to-thumb transfer prior to achieving active pinch. Despite pinning of the distal interphalangeal J Hand Surg Am.
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DISCUSSION Toe-to-thumb transfer for posttraumatic reconstruction is more frequently reported in adults than in the pediatric age group. Hand surgeons frequently recommend reconstruction by distraction lengthening r
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FIGURE 8: Amputation of all 5 digits of the left hand (R5m classification) in an 8-year-old boy due to burns.
of 6 thumb amputations, 1 of whom was a 12-yearold child, out of a series of 19 ray lengthenings with an average lengthening of 20 mm. Distraction lengthening requires a lengthy commitment and may not be well tolerated in a young child. If bony consolidation does not occur spontaneously, or if the parents do not accept allograft bone, secondary bone grafting of the resultant defect is frequently required and even a third-stage z-plasty procedure to deepen the thumb-index finger web space may be necessary. Although it results in a stable post, it does not provide much mobility, other than at the CMC joint and is much less aesthetic than a toe transfer. Tanzer and Littler15 and Littler16 first described pollicization by transfer of the index finger on its neurovascular pedicles. The middle, ring, and little fingers have been less frequently described for pollicization. Although pollicization was originally reported for posttraumatic thumb reconstruction, Buck-Gramcko17 revolutionized the reconstruction of children born with congenital thumb aplasia and hypoplasia by pollicization of the index finger. Posttraumatic thumb reconstruction in children by pollicization is rarely described in the literature.18e22 Foucher et al23 reported 27 pollicizations using the remnants of mutilated fingers, 78% of whom were described as having achieved a good or fair result. Weinzweig et al22 described pollicization of the stump of an
FIGURE 7: Donor site of the left second toe transfer 1 year after surgery.
or by pollicization of the index finger for posttraumatic reconstruction of the thumb in children, rather than microsurgical reconstruction. Microsurgery in children is perceived as extremely challenging because the pediatric vasculature is small and prone to vasospasm and postoperative monitoring is difficult. Matev10 first described thumb reconstruction by distraction lengthening of the metacarpal and stated that the prerequisites were an intact metacarpal, or at least two-thirds of the metacarpal, as well as satisfactory skin coverage of the thumb amputation stump. He initially reported distraction lengthening of 6 children between 10 and 14 years old who achieved lengthening of 2.5 to 3.8 cm after an average distraction of 35 days and spontaneous consolidation within 3 months. In a follow-up study of 8 patients aged 16 to 19 years, lengthening of 2 to 4 cm was achieved after distraction of 30 days and completion of the bony consolidation within 4.5 months.11,12 Kessler et al13 extended the technique of distraction lengthening to reconstruction of digits other than the thumb. Salom et al14 reported distraction lengthening J Hand Surg Am.
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FIGURE 11: Left great toeeto-thumb transfer 1 year after surgery.
FIGURE 9: Preoperative markings of a left great toe transfer.
FIGURE 12: Amputation of the left thumb through the MCP joint (R1m classification) in a 10-year-old boy.
reported 9 thumb reconstructions in 8 children by advancement pollicization of the remnant of the index finger onto the remaining proximal thumb metacarpal stump resulting in power pinch ranging from 2 to 10 lbs. Similarly, Ward et al29 described reconstruction of 15 thumb amputations at the level of the MCP joint due to burns in 11 children between 3 and 16 years of age who underwent pollicization of the index finger remnant. Seventy-four percent achieved good or excellent results in terms of pinch, grasp, and opposition, and 94% demonstrated overall
FIGURE 10: Left great toe transfer and associated anatomical markings. DPA, digital plantar artery; DPN, deep peroneal nerve; EHL, extensor hallucis longus; FHL, flexor hallucis longus; LDN, lateral plantar digital nerve; MDN, medial digital plantar nerve; SPN, superficial peroneal nerve; V, vein.
injured middle finger to reconstruct the thumb of a 17-year-old boy. Thumb reconstruction of the severely burned hands of children is especially challenging. May et al28 J Hand Surg Am.
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FIGURE 13: “Trimmed” left great toe transfer.
FIGURE 15: Donor site of the left foot 1 year after harvesting a “trimmed” great toe transfer.
TABLE 2.
Dominant Arterial Supply
FDMA
14 toes
FPMA þ vein graft
7 toes*
FDMA, first dorsal metatarsal artery. *Youngest patient with FPMA dominant anatomy was 3 years old.
Cooney and Wood4 described 5 children aged 3 to 9 years with posttraumatic thumb amputations who underwent reconstruction with second toe transfers. Shvedovchenko5 reported transferring toes to reconstruct fingers and thumbs in 17 children after traumatic amputations. From a series of 66 toe transfers in 40 children, Kay and Wiberg6 described 5 children between 3 and 10 years of age who underwent posttraumatic thumb reconstruction using a second toe in 4 children and a wraparound great toe in one child. Wei et al7 specifically described the reconstruction of 13 pediatric thumb amputations using toe transfers in 1997 with a follow-up report in 2003.8 Wolff and Posso9 in 2014 reported the results of second toe transfers for reconstruction of 9 children younger than 5 years after traumatic thumb amputation. Because thumb amputations in children are so rare, the small case series to date have not been adequate to define toe-to-thumb transfers as the gold standard for reconstruction of children’s thumbs after traumatic amputation. There is only 1 study comparing the functional outcomes of pollicizations with toe-to-
FIGURE 14: Appearance and opposition of the “trimmed” great toeeto-left thumb transfer to the little finger (Kapandji score 5).
improvement in hand function. There are very few reports of pollicization of a normal index finger for posttraumatic reconstruction of an amputated thumb in children, presumably because parents are reluctant to accept pollicization because this sacrifices a normal adjacent finger and perhaps the hand is then aesthetically inferior to a great toe transfer or the trimmed toe or Morrison wraparound variations. J Hand Surg Am.
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thumb transfers and no studies comparing the results of distraction lengthening with toe-to-thumb transfers. Michon et al30 compared the functional results of 33 pollicizations and 21 toe-to-thumb transfers in 6 categories—sensibility, mobility, strength, appearance, pinch, and grasp. For isolated thumb amputations (equivalent to the R1 classification), pollicizations were associated with better sensation, mobility, and pinch, whereas toe-to-thumb transfers provided better strength and grasp. For thumb and multiple finger amputations (corresponding to the R2-R4 classification), as well as amputations of the thumb in metacarpal hands (corresponding to the R5 classification), toe-to-thumb transfers provided superior outcomes in all 6 categories. Of the 21 toe-to-thumb transfers in our series, great toe transfers provided better function and appearance than second toe transfers. Selection of the donor toe, either the great toe or the second toe, was discussed extensively with the parents prior to surgery; however, many parents were reticent to accept the perceived cosmetic deformity of the foot after harvest of the great toe and chose the second toe. Kay and Bellew et al31,32 reviewed the psychosocial outcomes of 37 children who had undergone toe-to-hand reconstruction, including 5 children who had sustained traumatic amputations. Both the children and their parents reported a high level of satisfaction in terms of function, appearance, donor site, psychosocial well-being, and the reaction of others, with the children tending to be more positive than their parents. In a follow-up study of 25 children 10 or more years after toe-to-hand transfer, both the children and their parents continued to express the same high level of satisfaction, but at the 10-year stage, the positivity of the parental responses was equal to the children’s.33 Kaplan and Jones34 evaluated 10 adolescents who had previously undergone toe-to-hand transfers and 15 parents using the PODCI. Six dimensions were evaluated in parents of pediatric and adolescent patients and adolescent self-reports resulting in 18 groups. There were no significant differences between the toe transfer children and the normal pediatric population in 13 of 18 groups (72%). Adolescent patient scores were lower than normal in upper extremity function and transfer/ mobility dimensions, but adolescents self-reported higher scores in sports/physical function and happiness categories compared with their parents’ reported outcomes. Our series demonstrates that toe-to-thumb transfers in children after trauma are very reliable with no failures and no reexplorations in 21 transfers and with excellent long-term functional and psychosocial J Hand Surg Am.
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outcomes. In our series, no children have developed any gait disturbances, including the 2 children who underwent bilateral great toeeto-thumb transfers. All children regained pinch and grasp function and subjective sensation similar to the contralateral thumb or an adjacent finger. Children may have some difficulty cooperating with a therapist during the initial rehabilitation period, but it is generally assumed that children develop fewer tendon adhesions than adults. Toe-to-thumb transfer has become the accepted standard for reconstruction in adults after thumb amputation and based on this and previous series should be similarly offered to the parents of all children who have sustained thumb amputations. Toe-to-thumb transfer is a single-stage procedure that provides greater length and maintains growth potential compared with distraction lengthening. It also preserves all 4 fingers or the remaining fingers in contrast to pollicization. Second toeeto-thumb transfers are preferred for younger children because of better growth potential and an inconspicuous donor site, but great toeeto-thumb transfers become more favored for older children because of the better cosmetic appearance and to provide a larger sensate area in combined thumb and multiple finger amputations. It is the authors’ opinion that continuing to rely on distraction lengthening or pollicization, even for isolated R1 thumb amputations, can no longer be justified given the reliability and excellent results provided by performing a toe-to-thumb transfer in a child, and becomes even less indicated for R3-R5 thumb amputations associated with multiple finger amputations. REFERENCES 1. Cobbett JR. Free digital transfer. Report of a case of transfer of a great toe to replace an amputated thumb. J Bone Joint Surg Br. 1969;51(4):677e679. 2. Buncke GM, Buncke HJ, Lee CK. Great toeeto-thumb microvascular transplantation after traumatic amputation. Hand Clin. 2007;23(1):105e115. 3. 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(4):693e700. 4. Cooney WP 3rd, Wood MB. Microvascular reconstruction of congenital anomalies and post-traumatic lesions in children. Hand Clin. 1992;8(1):131e146. 5. Shvedovchenko IV. Toe-to-hand transfers in children. Ann Plast Surg. 1993;31(3):251e254. 6. Kay SP, Wiberg M. Toe to hand transfer in children. Part 1: technical aspects. J Hand Surg Br. 1996;21(6):723e734. 7. Wei FC, El-Gammal TA, Chen HC, Chuang DC, Chiang YC, Chen SH. Toe-to-hand transfer in children and adolescents. Plast Reconstr Surg. 1997;100(3):605e609. 8. Wei FC, Mardini S. Reevaluation of the technique of toe-to-hand transfer for traumatic digital amputations in children and adolescents. Plast Reconstr Surg. 2003;112(7):1870e1874.
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23. Foucher G, Navarro R, Medina J, Allieu Y. Pollicization, remains of the past or current operations [in French]. Bull Acad Nat Med. 2000;184(6):1241e1253. 24. Jones NF, Kaplan J. A new documentation system for congenital absent digits. Hand (N Y). 2012;7(4):391e399. 25. Brown EE, Chang WT, Jones NF. Temporary arteriovenous loop between the saphenous vein and first plantar metatarsal artery in toe-to-hand transfers. J Hand Surg Am. 2006;31(9): 1543e1545. 26. Jones NF, Gupta R. Postoperative monitoring of pediatric toe-to-hand transfers with differential pulse oximetry. J Hand Surg Am. 2001;26(3):525e529. 27. Kim JH, Yoon AP, Jones NF. Reverse radial forearm flap to provide arterial inflow to a toe transfer. Hand (N Y). 2017;12(2):154e161. 28. May JW, Donelan MB, Toth BA, Wall J. Thumb reconstruction in the burned hand by advancement pollicization of the second ray remnant. J Hand Surg Am. 1984;9(4):484e489. 29. Ward JW, Pensler JM, Parry SW. Pollicization for thumb reconstruction in severe pediatric hand burns. Plast Reconstr Surg. 1985;76(6):927e932. 30. Michon J, Merle M, Bouchon Y, Foucher G. Functional comparison between pollicization and toe-to-hand transfer for thumb reconstruction. J Reconstr Microsurg. 1984;1(2):103e110. 31. Kay SP, Wiberg M, Bellew M, Webb F. Toe to hand transfer in children. Part 2: functional and psychological aspects. J Hand Surg Br. 1996;21(6):735e745. 32. Bellew M, Kay SP. Psychological aspects of toe to hand transfer in children. Comparison of children and their parents. J Hand Surg Br. 1999;24(6):712e718. 33. Bellew M, Haworth J, Kay SP. Toe transfer in children: ten year follow up of psychosocial aspects. J Plast Reconstr Aesthet Surg. 2011;64(6):766e775. 34. Kaplan JD, Jones NF. Outcome measures of microsurgical toe transfers for reconstruction of congenital and traumatic hand anomalies. J Pediatr Orthop. 2014;34(3):362e368.
9. Wolff G, Posso C. Second-toe transfer for traumatic thumb amputation in children under 5 years: bone and soft-tissue growth. Tech Hand Up Extrem Surg. 2014;18(4):175e180. 10. Matev IB. Thumb reconstruction in children through metacarpal lengthening. Plast Reconstr Surg. 1979;64(5):665e669. 11. Matev IB. Thumb reconstruction through metacarpal bone lengthening. J Hand Surg Am. 1980;5(5):482e487. 12. Matev IB. The bone-lengthening method in hand reconstruction: twenty years’ experience. J Hand Surg Am. 1989;14(2 Pt 2):376e378. 13. Kessler I, Hecht O, Baruch A. Distraction-lengthening of digital rays in the management of the injured hand. J Bone Joint Surg Am. 1979;61(1):83e87. 14. Salom M, Aroca JE, Chover V, Alonso R, Vilar R. Distractionlengthening of digital rays using a small external fixator. J Hand Surg Br. 1998;23(6):781e784. 15. Tanzer RC, Littler JW. Reconstruction of the thumb by transposition of an adjacent digit. Plast Reconstr Surg (1946). 1948;3(5):533e547. 16. Littler JW. The neurovascular pedicle method of digital transposition for reconstruction of the thumb. Plast Reconstr Surg. 1953;12(5): 303e319. 17. Buck-Gramcko D. Pollicization of the index finger: method and results in aplasia and hypoplasia of the thumb. J Bone Joint Surg Am. 1971;53(8):1605e1617. 18. Stern PJ, Lister GD. Pollicization after traumatic amputation of the thumb. Clin Orthop Relat Res. 1981;155:85e94. 19. Reid DAC. Thumb reconstruction by pollicization in mutilating injuries of the hand. In: Reid DAC, Tubiana R, eds. Mutilating Injuries of the Hand. Edinburgh: Churchill Livingstone; 1984:141e156. 20. Dijkstra R. Thumb reconstruction in the severely damaged hand using finger remnants. Neth J Surg. 1989;41(1):11e14. 21. Brunelli GA, Brunelli GR. Reconstruction of traumatic absence of the thumb in the adult by pollicization. Hand Clin. 1992;8(1):41e55. 22. Weinzweig N, Chen L, Chen ZW. Pollicization of the mutilated hand by transposition of middle and ring finger remnants. Ann Plast Surg. 1995;34(5):523e529.
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