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Corresponding author at: Department of Hand and Foot Surgery, Department of Orthopedic Surgery, Qilu Hospital of Shandong University, 107 Wen Hua Xi Lu, Jinan 250012 China.
Foot injuries due to vehicular or other accidents are common. However, complete toe amputation is rare. This study explored the current protocols and clinical significance of toe replantation.
Methods
From December 2011 to December 2018, ten patients with 13 severed toes underwent toe replantation in our hospital. Seven cases were replanted antegrade, and three cases were replanted retrograde.
Results
All patients were followed for two to three years after toe replantation. One big toe underwent necrosis, while the other 12 toes survived completely. The appearance and feel of the successfully replanted toes were satisfactory, and the patients exhibited a normal gait.
Conclusion
Toe replantation can achieve an acceptable appearance and function of the foot and considerably reduce the psychological effects experienced by the patients. Increased clinical attention and application of toe replantation are needed.
Level of Evidence: Level IV, retrospective case series
Toes play a critical role in the ability of individuals to perform upright walking. Specifically, the hallux or big toe supports approximately 40% of the body's weight during the last phases of walking.
Foot injuries caused by traffic accidents or sports are common, but complete toe amputation is relatively rare. Numerous published reports have indicated that little or no disability has been associated with foot function in patients who underwent lateral or big toe reconstruction.
In addition, losing one or more toes impairs the integrity of the body and may be perceived as unaesthetic, resulting in possible adverse psychological consequences for some people, especially younger women.
Few cases of big toe replantation have been reported in the literature, and even fewer cases of lateral toe replantation.
The purpose of this study was to report the experiences of toe replantation performed in our hospital.
Methods
This was a retrospective study of toe replantation carried out in our hospital. Toe replantation is rare in foot and ankle surgery, and this review focused on our experience with this type of rare injury. During the treatment, no human tissue was used in any scientific research, and no experiments were conducted on humans. These patients were provided with routine medical treatment. After consultation with the medical ethics committee of our hospital, it was determined that this study did not require ethical approval. The ethics committee concluded that it was only necessary to obtain approval from the patients for their inclusion in the study. Therefore, informed consent was obtained from each patient.
From December 2011 to December 2018, ten patients (eight males and two females) with completely severed toes underwent toe replantation surgery in our hospital. Thirteen toes, including six big toes and seven lateral toes, were replanted. Four patients also experienced ancillary toe injuries, including phalangeal fractures and tendon injuries. The average age of the patients was 24.40 ± 17.65 years. The causes for the injuries included traffic accidents in six cases and injuries sustained due to machine operation in four cases. Six toes were amputated at the level of the proximal interphalangeal joint, three toes at the distal phalanx, three at the proximal phalanx, and one at the metatarsophalangeal joint. The time from the injury to surgery averaged 5.20 ± 1.55 h (Table 1).
The patients who underwent toe replantation were given general anesthesia and placed in a supine or prone position based on the specific conditions of the injury. Patients with amputation of the big toe, a proximal phalanx amputation, or requiring vein transplantation typically were placed in the supine position. Patients who experienced a distal interphalangeal joint amputation were placed in the prone position.
First, careful wound debridement was accomplished to remove the necrotic and contaminated tissues. The bilateral blood vessels, nerves, and dorsal veins of the toes were identified and marked. Bone shortening was a common procedure. Bone trimming was to reduce the risk of infection and allow direct repair of vessels and nerves. The end of the phalanx typically needed to be shortened by 2–5 mm.
The sequence for the retrograde toe replantation was as follows. The severed toes were penetrated with a 1.0 mm Kirschner wire, the plantar skin was sutured, and the flexor tendon was repaired using 5–0 PDS sutures. The bilateral arteries and nerves were anastomosed under a microscope, the ends of the phalanx were attached with the Kirschner wire, and the extensor tendon was sutured. Then, the dorsal vein of the toe was anastomosed under the microscope, and the dorsal skin of the toe was sutured. The sequence for the antegrade replantation of toes was as follows. A 1.0 mm Kirschner wire was used to attach the phalanx. The extensor and flexor tendons were sutured, the bilateral digital arteries and nerves were anastomosed under the microscope, the dorsal vein of the toe was anastomosed, and the skin was sutured.
Two severed big toes were rotationally avulsed, and the arteries had been pulled from the proximal end and were shortened. In these cases, the lateral dorsal vein of the foot was harvested for transplantation. The distal end of the transplanted vein was anastomosed with the proximal end of the bilateral digital arteries of the toe. This procedure was carried out under the microscope before the toe was replanted. Then, the antegrade replantation was initiated, and the proximal end of the grafted vein was anastomosed with the dorsal artery of the foot. The replanted toes were bandaged with sterile gauze, and the foot was immobilized using a plaster cast.
After surgery, the patients were required to undergo bed rest for one week in our microsurgery care unit. The blood circulation of the replanted toe was monitored every 2 h. Smoking and alcohol consumption were prohibited. The affected foot was elevated, and a heat lamp was used to keep the foot warm. Anti-inflammatory, anti-spasmodic, and anti-coagulation drugs were used, which were the same drugs used in finger replantation. Drug administration was stopped on the seventh day after surgery. The sutures were removed on the 14th post-surgical day, and physical therapy for the ankle joint was initiated. Radiographs were taken four weeks after the surgery, and the Kirschner wire was removed. Active and passive toe flexion and extension rehabilitation were performed after the surgery to achieve optimal function. The patients began to walk two months after the surgery.
All patients were followed for two to three years after toe replantation surgery. We measured the total active motion (TAM) of each digit, including the metatarsophalangeal and interphalangeal joints. Two-point discrimination was evaluated at the last follow-up. Subjective assessments were evaluated. The visual analog scale (VAS) described by Goldfarb et al. was used to assess the aesthetics of the replanted toes independently by two-fellowship trained microsurgeons, including the commissure, the scars, and the alignment of the toes.
The patients assessed the VAS of appearance (0=perfect appearance and 10=esthetically unacceptable) and function (0=no limitation and 10=severe limitations) separately.
Descriptive statistics were used. The data were reported as mean values and standard deviations, as well as frequencies and percentages where appropriate. There were no comparison groups. STROBE guidelines were adhered to throughout the manuscript.
Results
The ten patients were followed for two to three years. Among the 13 toes, 12 toes from nine cases survived, and one big toe became necrotic and was amputated. The cause for necrosis in one case was wound infection. The survival rate in this toe replantation cohort was 92%. There was no observable atrophy of the successfully replanted toes, and the physical appearance and sensation of the toes were good. The mean TAM for the replanted toes was 32.78±9.05° The two-point discrimination was 6.89±1.69 mm. The mean VAS score of aesthetics as determined by the doctor was 1.67±0.87. The patients exhibited a normal gait and were satisfied with their appearance and function. (Table 2)
The left foot of a 25-year-old female was cut by a machine, resulting in the complete amputation of her second to fifth toes. The second and third toes were severed at the level of the distal interphalangeal joint, and the fourth and fifth toes were severed at the level of the proximal interphalangeal joint (Figure 1, Figure 2, Figure 3). Antegrade replantation was performed with the use of a tourniquet. First, debridement was carried out, and the ends of the severed phalanges were then shortened by approximately 3 mm and rejoined with a 1.0 mm Kirschner wire (Figure 4). The flexor and extensor tendons were repaired using 4–0 PDS sutures. Using a microscope, the bilateral digital arteries were anastomosed using 10–0 polypropylene sutures, and the bilateral digital nerves also were repaired. Finally, two or three dorsal veins of each toe were anastomosed. The tourniquet was loosened, and the degree of blood circulation in the toes was assessed. Finally, the skin was sutured (Figure 5). After three years of follow-up, no significant difference was observed in the growth of the replanted toes two through five compared with the toes on the contralateral side, and the gait and function of the affected foot had returned to normal (Figures 6 and 7).
Figure 1Dorsal view of second to fifth toes amputation.
Complete toe amputation is rare in the clinical setting. Many physicians and patients accept a one-stage amputation or regional flap to cover the wound, which is less costly and requires less hospitalization time.
However, numerous biomechanical studies have reported that the center of weight-bearing pressure shifted laterally in cases of a lateral toe or big toe amputation, which can produce pain in the anterior aspect of the foot.
Toe amputation at the proximal end of the metatarsophalangeal joint will cause additional problems, including lameness or difficulty in running. Although there is no pronounced pain in standing or walking when lateral toes are amputated, there can be adverse psychological outcomes associated with toe amputations for young people, especially younger women. They usually feel uncomfortable when wearing sandals. In Asian countries, the concept of “whole reserved body” is still popular in traditional culture, so toe replantation deserves additional attention.
As a regional medical center, patients with severed toes are admitted to our hospital for the chance to undergo replantation. Using a detailed surgical protocol, 13 toes from ten patients have been replanted from 2011 to 2018 and followed for two to three years. The results were satisfactory. Every patient who was able to have the replanted toes survive was satisfied with the decision to undergo the surgical procedure. The patients could participate in sports activities and integrate into society without deliberately covering the replanted toes.
There are few published reports concerning the replantation of toes. The reason for avoiding toe replantation is that physicians and patients do not understand the importance of the first metatarsophalangeal joint, and most are concerned with the high failure rate.
(Table 3) Lin described 20 cases (with nine complete amputations) of replantation or revascularization of the big toe with an overall survival rate of 55 percent.
The main reasons for failure were the need for artery anastomosis in a challenging position, a tiny artery located at the level of amputation, and frequent vasospasms.
Vasospasm also occurred in the toe replantation patients in this study. For necrotic toes, amputation is preferred if the metatarsophalangeal joint is preserved. For patients who want to reconstruct the toe, an iliac bone graft, and free fat can be used to reconstruct the missing bone and the soft tissue toe defects.
Aesthetic multiple-toe reconstruction with combined iliac bone graft and wraparound free anterolateral thigh flap—a case report and literature review[J].
Our protocols were as follows. (1) The replantation procedure included anterograde and retrograde approaches. The anterograde replantation was carried out in the following order: debridement, bone fixation, flexor tendon repair, suturing of the nerves, arterial anastomoses, extensor tendon repair, venous anastomoses, and skin closure.
It is difficult to turn the foot over. Therefore, retrograde replantation was used to avoid position changes during surgery, which was easy and greatly improved the quality of the anastomoses and decreased the time in surgery.
The steps in the retrograde replantation procedure were accomplished in the following order: debridement, the distal retrograde passage of the Kirschner wire at the severed end of the toe, repair of the flexor tendon, anastomosis of digital arteries and nerves, internal fixation of the bone fracture, repair of the extensor tendon, anastomosis of the dorsal subcutaneous vein, and suture of the dorsal skin. (2) Only blood vessels that were in good condition underwent anastomosis. Most of the amputated toes were crushed or broken, and the blood vessels were contused. During debridement, a high-quality artery was selected for anastomosis. The nearest bifurcation of the blood vessel was removed from the amputation plane, and any tension on the anastomosed blood vessels was reduced by shortening the phalanx or using a vein graft. The phalanx was usually shortened by approximately 5 mm, and the joint was preserved. The grafted vein was harvested from the dorsalis pedis vein. A “Y” or “H” vein was ideal. For the big toe, the grafted vessel was anastomosed from the arteria dorsalis pedis to the toe artery. For the lateral toes, a vein graft linked the plantar metatarsal arteries with the toe artery. (3) For multiple toe replantations, the big toe replantation was prioritized. We preferred to repair the digital arteries of each severed toe to recover the necessary blood supply to each toe, and then the veins were anastomosed one by one. (4) Anti-coagulation drugs were used during the surgical procedure before the vascular anastomosis. Heparin was given at a dose of 10 U/kg/h, and administration continued for seven days following surgery. The dosage of heparin was adjusted according to a blood coagulation test (APTT) that was conducted daily. (5) It was critical to observe the degree of blood circulation in the replanted toes regularly to relieve the emotional tension experienced by the patients and establish complete trust and confidence between the patients and their physicians.
There is no consensus in the literature on the indications for toe replantation. We agree with the indication for the decision for toe replantation that the toes are complete or incomplete from guillotine-type severing to local crushing and proximal to the level of the interphalangeal joint. In addition, the patient should be less than 50 years of age, and the desires of the patients or their families must be taken into consideration
. Great efforts have been made especially for toe replantation in children for whom replantation is worthwhile because the subsequent growth of the replanted toe is good. A normal gait can be restored in children, although a 2 cm decrease in length in replanted great toes has been noted at the eight-year follow-up.
The development of advanced microsurgical techniques has facilitated the replantation of severed toes. The primary function of the toes is to assist with weight-bearing during walking. Thus, a normal shape for the foot is essential. Successful toe replantation can provide a normal shape to the affected foot, restore stability and the ability to jump and run, and restore the mental health of the patients. Therefore, toe replantation has useful clinical and social value.
Conclusions
The purpose of toe replantation is to restore several essential features, including the integrity of the foot anatomy, normal walking function, and an acceptable physical appearance. Although the number of patients in our group was limited, the success rate was high at 92%. We concluded that replantation of severed toes should be attempted as much as possible, especially for children and the big toe. Vein transplantation, anastomosing the dorsal artery of the foot, proper surgical positioning, and careful postoperative care likely improved the survival rate of the replanted toes, thereby allowing restoration of better foot function.
Funding
None.
Conflict of Interest
The authors declare that they have no conflicts of interest associated with this study.
Ethical approval
Our hospital ethics committee approved this research protocol. It was determined that this study did not require ethical approval. The ethics committee concluded that it was only necessary to obtain approval from the patients for their inclusion in the study. Therefore, informed consent was obtained from each patient.
Reference
Rolian C.
Lieberman D.E.
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Scott J.W.
Werbel W.
Walking, running and the evolution of short toes in humans.
Aesthetic multiple-toe reconstruction with combined iliac bone graft and wraparound free anterolateral thigh flap—a case report and literature review[J].
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