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Corresponding author: Venkat K. Rao, MD, MBA, Division of Plastic and Reconstructive Surgery, University of Wisconsin Health University Hospital, 600 Highland Avenue, Box 3236, Clinical Science Center, Madison, WI 53792.
The thumb is a crucial part of the hand, and traumatic thumb amputation is a devastating injury that significantly diminishes hand function. In situations in which replantation is not possible, great toe–to–thumb transfer is a well-established option for reconstruction. Although most studies describe excellent functional outcomes and patient satisfaction, there is a paucity of literature presenting long-term follow-up to determine whether these outcomes are maintained. In this case report, we present a case of great toe–to–thumb transfer performed 40 years ago and evaluate outcomes using validated questionnaires and standardized examination maneuvers. Our results highlight sustained patient satisfaction and excellent functional outcomes decades after the initial reconstruction.
“Great toes make great thumbs….”—Harry J. Buncke, MD.
The traumatic loss of a thumb is one of the most devastating hand injuries because of the profound impact on hand function. A toe-to-thumb transfer is indicated for patients who have sustained a crush or avulsion amputation to the thumb with maintained carpometacarpal stability.
Current reconstructive options include total great or second toe transfers or compound techniques. Although the selection between great toe transfer and other reconstructive options remains controversial, use of the great toe has been associated with better total active motion (TAM), stability, and higher aesthetic satisfaction.
Most studies specifically reporting great toe–to–thumb transfer outcomes have follow-up limited to 5 years. Therefore, the purpose of this report is to present a 40-year follow-up of a great toe–to–thumb transfer using validated questionnaires to highlight the longstanding functional and aesthetic benefits of this reconstructive technique.
Case Report
The patient was a 30-year-old right-hand dominant carpenter who sustained a work-related traumatic right thumb avulsion injury. He was initially evaluated at another facility and taken to the operating room for irrigation and debridement; however, replantation of the thumb was not attempted because of extensive tissue damage. The amputation occurred through the first metacarpal with significant dorsal skin loss. The patient was referred to the senior author (V.K.R.) to discuss thumb reconstruction options. A staged reconstructive plan, involving the use of a pedicled groin flap for soft tissue coverage, followed by a great toe–to–thumb transfer for thumb reconstruction, was proposed. The risks, benefits, and alternatives were discussed, and the patient elected to proceed with a staged reconstruction.
The patient underwent debridement and groin flap for soft tissue coverage without complication, followed by flap division and inset 1 month later. Approximately 3 months after his groin flap division, he was taken to the operating room for great toe–to–thumb transfer. The right great toe was harvested based on the first dorsal metatarsal artery from the dorsalis pedis artery and included both medial and lateral digital nerves, a dorsal vein, and flexor hallucis longus and extensor hallucis longus tendons. After performing transcutaneous fixation of the thumb with Kirschner wires, the extensor hallucis longus tendon was transferred to the residual extensor pollicis longus tendon and the flexor hallucis longus tendon was transferred to the residual flexor pollicis longus tendon using a weave technique. Given the level of injury, the metacarpophalangeal joint was not reconstructed. Then, venous anastomosis was performed, followed by end-to-end arterial anastomosis between the dorsalis pedis artery and superficial palmar branch of the radial artery. Two digital nerves along the ulnar and radial sides of the thumb were coapted to the digital nerves of the toe. The incisions were closed with reinset of the groin flap. The total operative time was 11.5 hours.
The thumb was monitored postoperatively with clinical examination and digital temperatures. His postoperative course was initially notable for moderate donor site pain; however, he was able to be discharged on postoperative day 10. The time to postoperative active range of motion hand therapy was 2.5 months. Given that he completed his postoperative occupational therapy at an outside facility, his detailed hand therapy records, including physical examination measurements, could not be obtained. He returned to the outpatient operating room three times in the 2 years after surgery for defatting of the groin flap.
The patient was seen in our clinic 40 years after his initial reconstruction for evaluation using validated questionnaires to assess long-term hand function (Michigan Hand Outcomes Questionnaire [MHQ], Disabilities of the Arm, Shoulder, and Hand) and quality of life (Short Form-36 Health Survey). Range of motion was measured with a goniometer. Grip and pinch strength were measured with a Jamar hydraulic hand dynamometer and Jamar hydraulic pinch gauge (Sammons Preston) and reported in kilopascals (kPa). Two-point sensation was tested using a Disk-Criminator (US Neurologicals LLC). Written consent was obtained for publication of this case report and the associated images.
The patient endorsed high satisfaction with his thumb reconstruction. He continued his career as a carpenter and, since retirement, enjoys completing home improvement projects. He denied any difficulties with activities of daily living but noted the development of bilateral osteoarthritis that has resulted in moderate pain. He noted seasonal cold sensitivity of the reconstructed thumb. He was overall pleased with the aesthetic result and believed that strangers commented more frequently on the surgical scars and soft tissue fullness of the groin flap than the digit. Regarding lower extremity function, he denied experiencing pain and had no limitations with gait.
His overall MHQ scores were comparable between the affected and unaffected hands. He scored highest in the MHQ scales of hand function (75/100) and satisfaction (83/100) (Table 1). His Disabilities of the Arm, Shoulder, and Hand score was 20/100. His Short Form-36 Health Survey results demonstrated the highest scores on physical functioning (80/100), mental health index (80/100), and general health (80/100) (Table 2).
Table 1Michigan Hand Outcomes Questionnaire Results Comparing the Toe Transfer Hand With the Contralateral Hand
Based on a scale of 0–100. For all scales except pain, a higher score represents better hand function. For the pain scale, a higher score indicates more pain.
Toe Transfer Hand
Contralateral Normal Hand
Difference
Function
75
80
5
Activities of daily living
70
85
15
Pain
65
60
5
Aesthetics
62.5
75
12.5
Satisfaction
83.3
87.5
4.2
Overall
60.1
67.1
7
∗ Based on a scale of 0–100. For all scales except pain, a higher score represents better hand function. For the pain scale, a higher score indicates more pain.
All the SF-36 scales are based on a scale of 0–100. For all scales, a higher score represents better hand function. For the pain scale, a higher score indicates less pain.
Scores
Physical functioning
80
Physical role
50
Pain index
45
General health
80
Vitality
70
Social function
62.5
Emotional role
66.7
Mental health index
80
SF-36, Short Form-36 Health Survey.
∗ All the SF-36 scales are based on a scale of 0–100. For all scales, a higher score represents better hand function. For the pain scale, a higher score indicates less pain.
Examination of the reconstructed thumb demonstrated well-healed scars. Compared with the contralateral side, the most noticeable difference of the transferred toe was greater volar pulp volume (Fig. 1). The TAM of the transferred toe was 35°. His examination was negative for extensor lag of the interphalangeal joint and thenar atrophy (Supplemental Video 1, available online on the Journal’s website at www.jhandsurg.org). Two-point discrimination of the transferred toe was a mean of 11 mm, compared with 6 mm on the thumb of the opposite hand. Average grip strength in the affected hand was 436.4 kPa, compared with 459.9 kPa in the unaffected hand. Lateral key pinch in the affected hand was 51% (Table 3). Three-view x-rays of the right hand demonstrated stable surgical changes but increased burden of osteoarthritis (Fig. 2). Examination of the lower extremity demonstrated well-healed surgical scars and deviation of the small toes medially with step-off to accommodate for the loss of the great toe (Supplemental Video 2, available online on the Journal’s website at www.jhandsurg.org).
Figure 1Clinical images of bilateral hands at the long-term follow-up. A Volar, B lateral, and C dorsal views demonstrating clinical results 40 years after right great toe transfer.
Figure 2Radiographic images of the right hand. A Posteroanterior, B oblique, and C lateral view x-ray imaging of our patient’s right hand at the 40-year follow-up demonstrating stable surgical changes and interval development of mild to moderate osteoarthritis of the radiocarpal, proximal interphalangeal, and distal interphalangeal joints.
The thumb is responsible for >50% of hand function; therefore, a successful reconstruction is paramount to a patient’s postoperative function and social well-being. This article presents long-term follow-up of a great toe–to–thumb transfer after traumatic thumb amputation. Our findings build on current outcomes data to highlight the long-term functional and aesthetic satisfaction of this reconstructive method.
Great toe-to-thumb transfer consistently demonstrates acceptable functional results, with a mean follow-up period of approximately 5.5 years. Buncke et al
reported their outcomes of 161 great toe transplantations and showed a mean return of grip and pinch strength of 77% and 67%, respectively. These findings are supported by a recent systematic review by Lin et al,
in which great toe transfer demonstrated a mean TAM return of 58°, 84% return of grip strength, and 81% return of key pinch strength compared with those of the contralateral hand. By comparison, at the time of long-term follow-up, our patient regained approximately 50% of TAM and 94% of grip strength, compared with those of his contralateral hand, despite not having his metacarpophalangeal joint reconstructed. His return of pinch strength was more limited at 59%. However, he reported high functional satisfaction as he returned to his occupation as a carpenter and, since retirement, continues to perform activities that require manual dexterity.
There is high satisfaction with the aesthetic outcomes of great toe transfers described in the literature. Woo et al
reported a score of 76 on the MHQ aesthetic scale, a slightly higher value than our patient’s score of 62.5. Nevertheless, our patient emphasized that he had high aesthetic satisfaction with the toe. Although potential aesthetic drawbacks include excess bulk of the great toe compared with that of the thumb, a 20% decrease in toe size occurs over the first year, improving similarity to the contralateral thumb.
, our patient’s function, pain, satisfaction, and overall scores were similar to those of the contralateral hand. Furthermore, his scores are comparable to those reported by Kroon et al
, who used the MHQ for patients with a diagnosis of hand osteoarthritis. Hand osteoarthritis has been associated with lower functional outcomes on both physical examination and standardized questionnaire evaluation, with functional scores inversely correlating to radiographic severity.
reported a significantly higher Disabilities of the Arm, Shoulder, and Hand score of 48.3 ± 26.3 for patients with moderate to severe osteoarthritis on radiographs than for those in a control group (39.5 ± 23.5), with mild or no radiographic disease. As demonstrated on our patient’s x-rays, he developed mild to moderate osteoarthritis in multiple hand joints. These findings may reflect that long-term functional impairments are more likely due to age-related degeneration than impaired durability of the reconstructed thumb.
We presented a case of great toe–to–thumb transfer with a 40-year follow-up, demonstrating the longevity of this reconstructive method to restore hand function. Our patient’s outcomes support that despite the initial surgical postoperative difficulties, long-term patient functional and aesthetic satisfaction is high.
Declaration of interests: No benefits in any form have been received or will be received related directly to this article. This article did not receive any funding.
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