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Toe to Hand Transfer Short QA

Toe to hand transfer:

The absence of one or more digits of the hand is a rare developmental abnormality. These unfortunate children face many problems especially when the missing digit is thumb. Along with missing digits there can be associated abnormalities in the involved hand or rarely in other parts of body. Another much more common cause of loss of fingers is accidental amputations from injuries. These injuries range from industrial accidents to road traffic accidents.

Both these groups can be immensely benefitted by the surgery of toe to hand transfer. After careful evaluation of the function of the remaining digits and patients work profile a suitable option is chosen by the surgeon (mutually agreeable to the patient).

The following information will be helpful and would guide one through the procedure, indications, advantages disadvantages and other details and would help one achieve reasonable conclusion.

Who are the ideal candidates for this surgery?

Children with loss of single digit do well without surgery unless the finger involved is thumb. Loss of thumb is definite indication either for toe transfer or pollicisation.

In adults, young healthy adults without other major diseases, who are well motivated to undergo the stressful period of operation and perioperative period, and physiotherapy, are suitable.

Which toe is routinely transferred?

The most commonly transplanted toe is the second toe, since it is the longest toe and combines all the useful characteristics of a digit (such as joints, a nail, sensitive pulp tissue, and the ability to grow) with a reliable blood supply. One second toe may be taken from each foot with surprisingly little effect on the function or appearance of the foot. When more than one toe is taken the cosmetic effect on the foot is considerable. This therefore limits the number of digits that can be reconstructed in the hand using this technique to a maximum of two.

What problems patient may have in the donor foot?

After the toe has been transferred, the foot is repaired by closing the gap between the third and the big toe. There will always be a scar on the foot. The foot surprisingly looks normal and the deformity is not apparent unless specifically observed.

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Following toe transfer, there is no reason to expect problems with walking or athletic activities.

How does the toe survive after transfer?

Whichever toe is transferred, its blood vessels (artery and nerve) must be successfully joined to similar vessels in the hand for it to survive. This intricate part of the operation is performed under the operating microscope (and so the operations is known as microsurgical toe to hand transfer) and is usually straightforward. Occasionally these vital vessels do not carry enough blood for the survival of the toe, and the transfer fails. This is very rare (probably occurring in less than 5% of cases) but leads to total failure of the transplant which is effectively "rejected".

Does the toe function normally?

Tendons (to allow movement where required), nerves (to allow feeling), and the bone must also be re-joined to suitable counterparts in the hand. In the case of the bone this is usually held together whilst it heals with fine pins (known as K wires). After the acceptance of toe and healing of bone; physiotherapy is started. Patients are expected to grow near normal sensation in 4 – 6 months. Normally the toe joints have lesser degree of movements when compared with hand. In best conditions the transferred toes will move slightly lesser than normal hand joints.

What will be the postoperative care?

Following microsurgical transplantation of a toe to the hand the whole arm is immobilised in a dressing which includes a plaster of paris splint. This will usually be left undisturbed for two or three weeks before the first change of dressing.

The first change of dressing will be performed either under a brief anaesthetic in theatre, or on the ward if only simple removal of the dressing is required. Usually stitches will be absorbable and do not require removal, whilst the pins used to fix the bones may be removed without an anaesthetic.

Will there be any splint?

During the first dressing under anaesthetic a splint is prepared to protect the new digit in the coming months. This is more easily made with the child still and serves a number of purposes. It splints the bones together until they unite, and protects the new digit from injury.

Is there any role for parents in postoperative care?

You may be asked to help your child further by gently stretching and working the joints as they recover, and again the hand therapist will explain this in greater detail as the need arises.

For at least the first year after surgery, the transferred part will feel the cold more than the other fingers, and will need to be kept warm in cold weather.

Will one surgery cure the problem completely?

Usually, there is a need for minor "secondary surgery" to correct some problem with the transferred digit. This may be planned from the outset and part of a staged treatment plan (for example, when muscles are later rearranged to allow greater range of movement in the digit) or may be unexpected (if a tendon becomes stuck and requires freeing to improve the movement of a joint).

This surgery is usually relatively minor for the child and should not be a cause for anxiety, with only a short period in hospital. Two particularly common reasons for secondary surgery are the adjustment of scars and the adjustment of bones.

Often we do not stitch a wound up tightly at the first operation (since the microscopic blood vessels are peculiarly sensitive to pressure) but allow it to heal with a skin graft (see separate information sheet). This may leave a rather less satisfactory scar that may be removed at a later date in a minor procedure.

Usually we obtain healing of bones in exactly the position we want them, but like all "fractures" the junction of the toe and the hand bones may heal slightly out of position. This is not usually a problem but occasionally it is necessary to undertake a small procedure to revise the position.

You will have regular follow-up appointments at the clinic in order to ensure that this aftercare goes smoothly.

Case 1: A. Non Replantable thumb; B Reconstructed by transferring 2nd toe.

Before After
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Case 2: A. Loss of index finger due to trauma; B. Rcconstructed with 2nd toe

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replantable-thumb-img replantable-thumb-img2