Immediate toe-to-hand transfer in acute hand injuries: overall results, compared with results for elective cases

In the past 5 years, 25 mutilated digits were reconstructed with immediate toe-to-hand transfers after acute hand injuries, for 21 patients. The overall results of the immediate toe-to-hand transfers were evaluated and compared with the results of 65 elective procedures performed during the same period by the same surgeon. There were 15 cases of great toe-to-hand transfer for thumb reconstruction, two cases of second toe transfer for index finger reconstruction, and four cases of simultaneous two-toe transfer for reconstruction of multiple-digit amputations. Two cases (two of 25 cases, 8 percent) were successfully salvaged with emergency reexploration. The incidences of emergency reexploration and postoperative infection were not significantly different from those for elective toe-to-hand transfer cases. The duration of industrial insurance coverage was much shorter than for elective cases, averaging 225 days (p < 0.001). Approximately 44 percent of the patients maintained their original jobs after immediate toe-to-hand transfer. The subjective satisfaction self-assessment scores of aesthetic appearance and function for the newly reconstructed thumb averaged 80 and 88 (of a total score of 100), respectively. Although satisfaction was lower than for elective reconstruction (p < 0.001), it was higher than for reconstruction of other digits. The donor-site appearance after great toe harvesting was mostly unsatisfactory. Immediate toe-to-hand transfer provides many advantages over the elective procedure in acute hand injuries, including single-stage reconstruction, shortened convalescence, early return to work, and socioeconomic efficiency. Because there were no significant differences in the success rates, frequencies of complications, or ultimate functional results, immediate toe-to-hand transfer is a safe and reliable procedure that is indicated for specific cases of acute digital amputation.     

Reconstruction of bilateral metacarpal hands with multiple-toe transplantations.

Bilateral metacarpal hands, if not treated properly, leave a patient without prehensile ability in both hands. Since 1990, six patients with bilateral metacarpal hands caused by accidents have undergone reconstruction with multiple-toe transplantations. Four or five toes were used for each patient, with a total of 27 toes transplanted to the hands. There was no toe loss. One nonunion in a middle-finger reconstruction was treated successfully with bone grafting. Secondary operations for functional improvement included one joint fusion and one flexor tendon tenolysis. Only one patient required excision of a plantar callus 42 months postoperatively, whereas the other five patients reported no major donor-site problems in an average 57 months of follow-up time. The six patients continue all their daily activities independently. Although their jobs were changed, all adult male patients were able to return to regular work. Principles of reconstruction to achieve satisfying prehensile function combined with minor donor-site morbidity in bilateral metacarpal hands include an adequate soft-tissue coverage before toe transplantations, selection of digits to be reconstructed based on functional and individual requirements, selection of toes and number of toes to be harvested based on consideration of usefulness for the hands and of foot morbidity, and consideration of thenar function in planning the sequence of transplantations. In conclusion, given thorough planning, multiple toe-to-hand transplantations can provide adequate prehensile function in reconstructed bilateral metacarpal hands with acceptable donor-site morbidity.     

Simultaneous multiple toe transfers in hand reconstruction

Our experience with simultaneous transfer of two or more toe units to the same hand where multiple digits were missing is presented. Forty-six toes from 38 feet were transferred to reconstruct 19 hands in 19 patients. The transfers consisted of 7 combined second and third toe units and 32 single toes. Three patients had a primary and 16 patients had a secondary reconstruction. There was one complete and one partial failure. The two-point discrimination ranged from 6 mm to protective sensation. Total active movement averaged 57 degrees in the thumb and 127, 93, 71, and 68 degrees, respectively, in the fingers reconstructed at middle phalanx, proximal phalanx, metacarpophalangeal joint, and metacarpal head. Pulp-to-pulp pinch averaged 2.4 kg in patients who had thumbs reconstructed and averaged 3.0 kg in patients who had normal thumbs. There was no cold intolerance, and no significantly disabled foot occurred except one with scissoring deformity. Simultaneous multiple toe transfer in hand reconstruction is feasible without increased complications both in primary and secondary wound conditions. It is time-effective and cost-effective.     

Ten-digit replantation

A case is presented of replantation of 10 digits at the proximal phalangeal level. Seven digits survived. Osteotomies and flexor tenolysis were done on the right thumb, long, and ring fingers and left index and long fingers 11 months later. A toe-to-hand transfer was done to reconstruct the failed left thumb replantation. Functional and sensory recovery is satisfactory.     

Fingertip reconstructions using partial-toe transfers

Fifty-six partial toes were transferred to reconstruct fingertip deficits. The transfers from the big toe mainly consisted of 3 trimmed big toetips, 3 vascularized nail grafts, 3 onychocutaneous flaps, 19 thin osteo-onychocutaneous flaps, and 2 hemipulp flaps. The transfers from the second toe mainly consisted of 8 trimmed second toetips, 5 reduced second toes, and 9 whole distal phalanges. The average values of postoperative sensory recovery of the osteo-onychocutaneous flaps including the vascularized nail grafts were 3.1 (Semmes-Weinstein test) and 6.3 mm (moving two-point discrimination) at 2.6 years after the transfer; those of the thin osteo-onychocutaneous flaps were 3.1 and 7.2 mm at 2.0 years after surgery; those of the trimmed big toe tip transfers were 3.61 and 6.5 mm at 1.8 years after surgery; and those of the trimmed second toetip transfers were 3.37 and 6.3 mm at 2.6 years after transfer. Those of the distal phalanx of the second toe were 3.41 and 7.9 mm at 1.2 years after surgery, and those of the reduced second toe were 3.2 and 6.7 mm at 10.6 months after surgery.     

Minimizing impairment in laborers with finger losses distal to the proximal interphalangeal joint by second toe transfer

Traditionally, toe-to-hand transfers have been reserved for thumb amputations or for use after severe mutilating injuries. The authors report their experience with the use of second toe-for-finger amputations with preserved or reconstructible proximal interphalangeal joints in manual workers. The aim of the procedure was to reduce impairment and to upgrade the hand from a functional and cosmetic standpoint. Fifteen second-toe wrap-around or variations were carried out on 11 adults (18 to 41 years old). Four patients with two or more finger amputations received two sequential second toes; four patients with two finger amputations received one toe; and each of three patients with single-digit amputation received a single toe. All but one amputation were performed less than 3 weeks after the accident. All toes survived. Range of motion at the native proximal interphalangeal joint was more than 90 percent in all patients but one; however, it was minimal at the transplanted joints. Patient satisfaction was high from a cosmetic and functional standpoint. Ten of 11 laborers resumed their previous activity. On the basis of this experience, a classification with aesthetic and functional implications is proposed to help in the decision-making process when dealing with multidigital injuries. It is concluded that second-toe transfer is an excellent choice for finger amputation distal to the proximal interphalangeal joint in laborers. Its prime indication is for amputations of two fingers where at least one toe should be transferred, as required, to achieve an "acceptable hand" (three-fingered hand). Early transfer allows salvage of critical structures from the damaged finger, such as joints, tendons, and bone, that otherwise would be lost. Early transplantation is highly recommended.     

A comparison between primary and secondary toe-to-hand transplantation

Although primary toe-to-hand transplantation is performed with increasing frequency, its use is still controversial because of the lack of any comparative studies documenting its safety and efficacy. Between August of 1990 and December of 1993, 175 consecutive toe-to-hand transplantations for crush and avulsion injuries were performed in 122 patients. The average interval between injury and primary reconstruction was 7 days, and the average interval between injury and secondary reconstruction was 10.7 months. Follow-up ranged from 18 to 91 months, with an average follow-up of 58 months. There were 31 primary transplantations and 144 secondary transplantations. The survival rate was 96.8 percent (30 of 31) for primary reconstruction and 96.5 percent (139 of 144) for secondary reconstruction. Intraoperative anastomotic revision was necessary in 3.2 percent (one of 31) of primary transplantations and 7.6 percent (11 of 144) of secondary transplantations. Three primary toe-to-hand transplantations (9.7 percent) and 17 secondary toe-to-hand transplantations (11.8 percent) were re-explored in the postoperative period. Each group had one superficial infection. The infection rate was 6.5 percent and 0.7 percent in the primary and secondary groups, respectively. Other complications included partial skin loss, which occurred in one patient (3.2 percent) in the primary group and six patients (4.2 percent of 144 transplantations) in the secondary group. Secondary procedures to improve function were necessary in six secondary transplantations (4.2 percent) and in none of the primary transplantations. There was no statistical difference between the two groups in terms of survival, intraoperative anastomotic revision, re-exploration, future secondary procedure, infection, and complications. This series demonstrates that primary toe-to-hand transplantation can be performed in the suitable candidate safely with as much success as secondary reconstruction. Primary toe transplantation can potentially reduce the overall period of recovery and rehabilitation, allowing the patient to return to work sooner. Further study to evaluate and compare the final functional outcome and return to work time between primary and secondary toe-to-hand transplantation is needed.     

Microsurgical toenail transfer to the hand

Free nonvascularized toenail grafts have been used to reconstruct congenital or traumatic nail defects of the thumb or finger. Unfortunately, these transfers often result in deformity or atrophy. To avoid these undesirable results, microsurgical free vascularized toenail transfer was performed in 10 patients, 3 for congenital nail absence and 7 for traumatic nail defects. Patient age averaged 17 years (range 2 to 32 years). In contrast with previous reports, the whole big or second toenail complex without pulp was used in reconstruction. All 10 nails were successfully transferred with complete survival. No digits required reexploration. There were no donor- or recipient-site problems. Follow-up averaged 3 years, with a range of 14 months to 5 years and 4 months. Appropriate nail growth occurred in the congenital patients. No atrophy of the nail complex was found as long as sufficient bony support was present (9 of 10 cases). Whole free vascularized toenail transfers for reconstruction of congenital and traumatic nailbed defects achieve excellent aesthetic results while maintaining normal hand function.     

Microsurgical transfer of the second toe for congenital deficiency of the thumb

Twelve second-toe transfers have been performed to substitute for thumbs congenitally deficient through constriction ring syndrome, symbrachydactyly, and true transverse arrest. The children were on average 3 years of age, and the youngest was undertaken at 10 months. Anatomic variations were the rule in the six cases of transverse absence and the three cases of symbrachydactyly, requiring nerves, tendons, and vessels in the toe be connected to whatever appropriate structure could be located. All transfers survived, and only one required exploration. Sensation appeared good in the 11 seen in later review, but interphalangeal motion was achieved in only 3. However, good use was made of the digit by all except one patient, an early patient in whom there was not an adequate skeleton on which to base the transfer. This small series suggests that in appropriate cases toe transfer can be undertaken early for congenital deficiency with little fear of encountering microsurgical problems unique to the infant.     

Reverse anterior tibial artery flap for reconstruction of foot donor site

The foot offers numerous useful options for hand reconstruction. Hallux transfer, dorsalis pedis flap, second toe transfers, and toe joint transfers offer good functional results in reconstructed hands. However, when the donor site is repaired with skin grafts, delayed wound healing, scarring, and contractures often result. Poor cosmesis of the donor site and altered gait are the main drawbacks of the procedures. The authors propose a new concept of primary reconstruction of the donor foot using a reverse-flow anterior tibial flap from the same leg. Two flaps are raised from the same anterior tibial vessel system in continuity as a distal free flap for hand reconstruction and as a proximal reverse-flow pedicled flap to resurface the donor defect. This technique allows good flap reconstruction of the foot donor site, reducing morbidity and limiting the operation to the same limb. The authors report their experience of 33 cases. There were no failures. Primary wound healing was achieved in the foot donor site, with acceptable cosmesis and satisfactory function.     

Microvascular free-tissue transfer in children

We have reviewed our experience with 22 microvascular free-tissue transfers in children. Ages range from 2 to 14 years; the success rate was 96 percent. Two patients underwent reexploration for postoperative hemorrhage, possibly due to treatment with low-molecular-weight dextran. No vessel spasm was observed, compared with a 28 percent incidence in our adult series of 154 patients. The vessels were in pristine condition. Operative time was shorter (6.1 hours) than in our adult series (9.7 hours). Average hospital stay was 10 days (compared to 23 days for adults). All children have resumed almost normal activity within 2 months (4 months for adults). Results of this study indicate that microvascular free-tissue transfer can be accomplished safely and expeditiously in children. Care should be taken in preoperative and postoperative planning, however, especially concerning immobilization.     

Usefulness of a first transferred free flap vascular pedicle for secondary microvascular reconstruction in the head and neck

The authors found that a previously transferred free flap vascular pedicle, distal to the first microvascular anastomosis, can be used as a recipient vessel for an additional free flap transfer. Free flap transfers were performed by using the standard procedure in patients with head and neck cancer. The mean age of the patients was 62 years. Five patients were men and three were women. A second free flap was transferred for secondary primary head and neck cancer in two cases, facial deformity in two cases, osteomyelitis of the skull in two cases, recurrent cancer in one case, and exposure of a mandibular reconstruction plate in one case. The interval between the two operations was from 4 months to 12 years (median, 21 months). All secondary free flaps were performed successfully. In two cases, the external jugular vein proximal to the previously anastomosed site was used for venous drainage. In another case, additional venous anastomosis was performed for flap congestion. It became clear that a previously transferred free flap vascular pedicle could be used as a recipient vessel for microvascular anastomosis. This is an excellent procedure for additional free flap transfers.     

Transfer of cultured rabbit embryos

Embryo transfer experiments were carried out to study the developmental capacity of cultured rabbit embryos when transferred to recipients of variable postovulatory maturity. Rabbit embryos were flushed from the oviduct at 26 hours postcoitum (pc) and cultured in a modified Ham's F-10 medium supplemented with bovine serum albumin (BSA) for a period of 70 hours. At 96 hours pc the cultured embryos, which ranged from the early morula to the expanding blastocyst stage, were transferred to pseudopregnant recipients mated to vasectomized males 36 to 96 hours prior to the transfer procedure. Greatest embryo survival occurred when transfers were made to either the oviducts or uterine horns of recipients at 48 hours pc. Intermediate results for both implantation rates and number of young born were obtained with recipients at 36, 60, 72, and 84 hours pc. Transferred embryos consistently failed to survive the uterine environment of recipients 96 hours pc at transfer although this group was synchronous with embryonic chronological age. Oviductal transfers were generally more successful than uterine transfers. Markedly higher rates of embryo survival resulted from embryos that were collected 60 and 72 hours pc and transferred directly to synchronous recipients without an interim period of culture. Dissimilarity of development for in vivo grown rabbit embryos and those cultured in synthetic medium is demonstrated.     

Sixty-four cases of thumb and finger reconstruction using transplantation of the big toe skin-nail flap combined with the second toe or the second and third toes

The purpose of this article is to introduce the results of thumb and finger reconstruction using transplantation of the big toe wraparound flap combined with the second toe or the second and third toes. Between August of 1981 and December of 1998, in a series of 64 cases involving 58 patients with digitless hands, either (1) the thumb and index fingers were reconstructed by transplantation of a big toe wraparound flap combined with the adjacent second toe harvested from the ipsilateral foot; or (2) the thumb, index, and long fingers were reconstructed by transplantation of an ipsilateral big toe wraparound flap combined with the adjacent second and third toes. The phalanx of the new thumb was usually an iliac block. The success rate of this series was 92.2 percent. At long-term follow-up, the average static 2-point discrimination was less than 10 mm. The distance between the tip of the new thumb and the new index finger ranged from 6 to 10 cm (average, 8 cm). Opposition action was nimble and forceful. The patients could lift a 6- to 12-kg weight with their reconstructed digits. All patients were satisfied with their new hands and were able to use them in their daily activities. The transplants for reconstructing the thumb and fingers are harvested from the same foot in a procedure known as one-foot donation. Function of the bilateral digitless hand can be recovered with this procedure.     

Reconstruction of the thumb with a trimmed-toe transfer technique

The trimmed-toe transfer is a new modification of the existing great-toe transfer technique for thumb reconstruction. This procedure was devised to circumvent patient concerns regarding overly large reconstructed digits following total great-toe-to-hand transfer. This technique involves reduction of both the bony and soft-tissue elements along the medial aspect of the transferred great toe in order to produce a more normal sized thumb. Follow-up of the initial 20 patients from 1983 to 1986 demonstrates good stability, grip strength, and pinch strength. Although compared with total great-toe transfer a modest reduction in joint motion of trimmed toes has been observed, the overall appearance and usefulness of the reconstructed thumbs have been excellent.     

Bead-to-bead transfer of chinese hamster ovary cells using macroporous microcarriers

Chinese hamster ovary cells (CHO-K1) were cultivated in macroporous gelatin microcarriers (CultiSpher G and CultiSpher S) in spinner flasks and a 5 1 bioreactor. Near-to-confluent cultures were harvested by bead-to-bead transfer where intact microcarriers with cells were transferred from a spinner flask to another spinner flask or to the bioreactor with naked microcarrier beads. Successful bead-to-bead transfer was achieved in various split ratios. The duration of attachment seemed to be important where the direct contact of beads to each other can be achieved by intermittent stirring. Repeated transfers were performed and at least four transfers in spinner flasks were achieved.Two variations of bead-to-bead transfer were performed in the 5 1 bioreactor either by seeding the bioreactor with near-to-confluent beads cultivated in spinner flasks orin situ transfer by adding fresh beads to the bioreactor. As in the spinner case, attachment was achieved by intermittent stirring where donor beads were in close proximity to the acceptor beads. Again successful transfers were obtained as evidenced by the good growth on acceptor beads where cell yields were in the range of 3100–4500 cells/bead.The results suggest that bead-to-bead transfer of CHO-K1 cells can be easily performed and do provide an alternative route to applications where dissolution techniques may not offer an efficient solution.     

Outcomes of scapula stabilization in obstetrical brachial plexus palsy: a novel dynamic procedure for correction of the winged scapula

Among the late consequences of obstetrical brachial plexus palsy is winging of the scapula, a functional and aesthetic deformity. This article introduces a novel surgical procedure for the dynamic correction of this clinical entity that involves the dynamic transfer of the contralateral trapezius muscle and/or rhomboid muscles and anchoring to the affected scapula. In more severe cases of scapula winging, the contralateral latissimus dorsi muscle may also need to be transferred to achieve dynamic scapula stabilization. The outcomes of this novel surgical procedure were analyzed in relation to the effect on abduction, external rotation, growth of the scapula, and distance of the scapula from the posterior midline. The results were analyzed in 26 patients who underwent this procedure and had adequate follow-up. The mean patient age was 6.39 years. Fourteen (54 percent) had a diagnosis of Erb palsy, and 12 (46 percent) had a diagnosis of global paralysis. All 26 patients had an additional secondary procedure performed prior to or simultaneously with the scapula stabilization procedure. In 19 patients, the contralateral trapezius was transferred and anchored to the medial border of the winged scapula alone, but in seven cases the underlying rhomboid major was transferred along with the trapezius muscle to provide sufficient scapula stabilization. In five cases in which the scapula winging was severe, the contralateral latissimus dorsi muscle was transferred at a second stage. After this procedure, all patients demonstrated improved scapula symmetry. The mean increase in abduction was 18 degrees (p < 0.001), the mean increase in external rotation was 19 degrees (p < 0.001), and the mean increase in anterior flexion was 12 degrees (p = 0.015). The improvement of the relative position of the winged scapula on the posterior thorax was analyzed by measuring the distance of the inferior angle of both scapulae from the midline, then calculating the difference between normal and affected sides and comparing this value before and after the scapula stabilization procedure. This value preoperatively was 3.24 cm; postoperatively it decreased to 0.36 cm (p < 0.001), demonstrating a statistically significant improvement.     

Microvascular soft-tissue transplantation for reconstruction of acute open tibial fractures: timing of coverage and long-term functional results.

Seventy-two patients with Gustilo grade IIIB open tibial fractures were treated with free-tissue transfers. If successful free-tissue transfer for soft-tissue reconstruction is performed within 15 days of injury, the risk of major complications is 3.6 percent. Long-term retrospective follow-up (mean 42 months) revealed successful limb salvage in 93 percent, good aesthetic results in 80 percent, and patient satisfaction in 96 percent. However, 66 percent of patients exhibited significantly decreased range of motion of the ankle, 44 percent experienced swelling and edema requiring elastic support and activity modification, and 50 percent occasionally required an assistance device for ambulation. The long-term employment rate was 28 percent, and no patient returned to work after 2 years of unemployment. In contrast, 68 percent of amputees after lower extremity trauma over the same period returned to work within 2 years. Patients need to realize the disruptive nature of this injury on their family, job, and future.     

Froid hivernal et port exclusif de chaussures de sport en tissu par une adolescente : effets tardifs en tomoscintigraphie osseuse et en résonance magnétique nucléaire

We present a rare clinical case of a 14-year-old adolescent girl from central Switzerland with an algoneurodystrophy of the left foot and leg 6 months after grade I frostbite(s) of the feet. After 6 months of constant pain of the digits, not attenuated by non steroid anti-inflammatory drugs, MRI of the feet reveals a predominantly left-sided and distal medullary edema, limited to the phalanges. Bone scintigraphy shows a predominantly left-sided diffuse feet hypoperfusion, coupled with an increased bone uptake of the left leg at late images. Inadequate life-style of adolescents, i.e., exclusively wearing shoes made of cloth and not of leather – even with temperatures below 0 °C in winter – might be a cause of chronic pain of foot digits. This is a rare demonstration of late effects of cold on foot digits by combined MRI and bone scintigraphy. Algoneurodystrophy in children and adolescents is an underdiagnosed clinical entity.