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Microsurgery and free tissue transfer play a vital role in the modern practice of reconstructive surgery. Prior to the advent of microsurgical free tissue transfer pedicle flaps were the workhorse of a reconstructive surgeon. We report a case of thumb reconstruction by pedicled transfer of the second toe with functional and aesthetic outcome. This case was performed in Pakistan where microsurgical facilities were not available.
Thumb reconstruction by toe to hand transfer represents one of the pinnacles of reconstructive surgery. With the introduction of a free microvascular transfer,
this technique has become an integral part of the armamentarium of all contemporary hand surgeons. However, free tissue transfer is not always possible and we describe a case of thumb reconstruction by the pedicled transfer of the second toe.
2. Case report
A 37 year old right handed labourer and part time postman, was referred for reconstructive surgery. He had sustained multiple injuries to both upper limbs while working on a wheat threshing machine, six weeks prior to reference. The patient had sustained a traumatic amputation of his left arm through the proximal third of the humerus and amputations of his right thumb and index finger at the level of the metacarpophalangeal joints (Fig. 1) . There was a healed fracture of the middle phalanx of his middle finger. The patient was otherwise fit and healthy.
Figure 1Injuries to both upper limbs sustained by a 37-year-old right handed labourer in a wheat-threshing machine accident.
Elective methods of thumb reconstruction were discussed and a pedicled right second toe to thumb transfer planned (Fig. 2) . The position of the hand and foot during the procedure were explained in detail to the patient.
Figure 2Pre-operative picture of the defect and donor site.
The dissection of the right hand was first performed to prepare the bone, tendon and nerve ends. The right second toe was dissected as for a free tissue transfer.
The dissected toe was kept in continuity with a 7.5 cm wide, proximally based dorsalis pedis artery flap. The skin flap included the dorsalis pedis artery in continuity with the first dorsal metatarsal artery. The perforators from the plantar vessels were divided. Two superficial veins and the venae comitans accompanying the arterial pedicle, were also preserved. The incision on the plantar surface was extended proximally to harvest sufficient length of the flexor tendons and digital nerves.
The second toe was separated from the metatarsus at the metatarsophalangeal joint keeping the joint capsule attached to the proximal phalanx. The digital vessels to the second toe were carefully preserved and the extensor tendon dissected and divided. The toe was raised with the dorsalis pedis artery flap to the level of the ankle joint, allowing easy transfer to the right hand.
The second toe was fixed by repairing the capsule of the metatarsophalangeal joint to the capsule remnant on the neck of the thumb metacarpal. The tendons and digital nerves were repaired using standard techniques. The majority of the hand wound was covered with the skin of the second toe and dorsum of the foot. A small raw area on the dorsum of the hand required a skin graft. The head and part of the shaft of the second metatarsus were excised and the first and third rays approximated using nylon sutures and the donor site skin was closed without tension.
The right hip and knee joints were maintained in full flexion with the help of crepe bandages. A 2/0 silk stitch was placed between the wrist and the ankle to secure the pedicle and this was removed after two days. The patient was uncomfortable for 48 h following the procedure but then coped well to maintain the required position (Fig. 3) . The vessels in the pedicle were divided after two weeks and complete division was performed after three weeks. The patient was discharged one week after division of the pedicle (Fig. 4) . He was advised about passive and active mobilization of his new thumb. The donor defect healed uneventfully. The patient regained full range of movement of his leg and arm within one week.
Figure 3The position of the right hand and foot during the procedure.
At follow up, at one year the patient had a satisfactory range of movement of his thumb (Figure 5, Figure 6) . There was active range of motion of 30° at the metacarpophalangeal joint and 70° at proximal interphalangeal joint (of the transferred toe). The patient had gained precision and pulp pinch (Fig. 7A and B) , chuck grip and, span (Fig. 8) and power grasp. He had good recovery of sensation with two point discrimination of 6–7 mm. He obtained sufficient independence to feed, clean and dress himself (Fig. 9) . He rides a bicycle and was back to work as a postman.
A toe to hand transfer is an important method of thumb reconstruction. In 1898, Nicoladoni first described the pedicled transfer of a second toe to reconstruct the thumb of a 5 year old boy.
transferred the great toe of a monkey to the thumb position after repairing both the arteries and veins. The first clinical case of a free tissue transfer was reported in 1969 by Cobbett
who performed a great toe to hand transfer in a 31 year old man, who had traumatically lost his thumb. No operation in microvascular surgery has added a greater degree of improvement to its predecessor and a free toe to thumb transfer has taken its eminent and deserved role as an important method of thumb reconstruction.
However, situations can arise where microvascular facilities are not available. We have described a successful case of thumb reconstruction by the pedicled transfer of the second toe. A review of the literature confirms that this procedure is now seldom performed.
The patients left arm had been amputated at the level of the humerus and there was no index finger available for pollicisation. Thumb reconstruction was required to restore useful hand function. Treatment options included an iliac crest bone graft with soft tissue cover, using either a reversed radial forearm flap or groin flap. However, it was felt that the bulky appearance, absence of sensation and lack of movement of this new thumb would offer a poor substitute. A toe to hand transfer provided the best reconstructive option to restore strong and fine manipulative hand movements.
Following a detailed explanation of the procedure to the patient and his relatives a toe to thumb transfer was planned. The senior author (MR) had experience of microsurgery including free toe transfer but in this case, a free microvascular transfer could not be attempted because of lack of facilities and team support. The patient could not afford to travel to a distant centre.
The operative technique for a pedicled toe to hand transfer is identical to that of free tissue transfer, except that the toe is kept attached by a pedicle based on the dorsalis pedis and skin vessels. In the case we describe, maintaining the appropriate post-operative position was not difficult in a cooperative patient, after the first 48 h. We have a vast experience of distant pedicle flaps transferred as cross leg or forearm to face. Long-term joint stiffness has not been a problem in our cases.
We have achieved a very satisfactory result following a pedicled transfer and would recommend this method of thumb reconstruction to other surgeons if microvascular facilities are not available.
References
Cobbett J.R
Free digital transfer: report of a case of transfer of a great toe to replace an amputated thumb.
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