Second toe to index finger transfer

British Journal of Plastic Surgery' (2000), 53, 324-330 9 2000 The British Association of Plastic Surgeons doi: 10.1054/bjps.2000.3345 BRITISH JOURNAL OF ~ PLASTIC SURGERY Second toe to index finger transfer B. C. Cho, D. H. Lee*, J. W. Park, J. S. Byun and B. S. Baik Department of Plastic and Reconstructive Surgery, Kyungpook National University Hospital, Taegu; and * Choongnam National University Hospital, Taejeon, Korea SUMMARY. Between April 1994 and May 1998, 15 amputated index fingers were treated based on three classifications: group 1 consisted of patients with index finger defects immediately proximal to, yet including, the distal interphalangeal joint, group 2 were those patients with defects from the proximal part of the distal interphalangeal joint to the distal part of the proximal interphalangeal joint and group 3 comprised patients with more proximal defects than group 2. With a total of six men and nine women, seven cases were included in group 1, five in group 2 and three in group 3. For the patients in groups 1 and 2, only a partial length of the second toe was transferred to the index finger, whereas in group 3 the total length of the toe needed to be transferred. The results can be summarised as follows: 1. The two-point discrimination of the reconstructed index tip was 2.2 mm for group 1, 2 mm for group 2 and 2.3 mm for group 3. 2. In group 1, the average range of motion in the transferred toe was 43.8 ~ in the distal interphalangeal joint. In groups 2 and 3, the average range of motion in the transferred toe was 30 ~ and 30.7 ~ in the distal interphalangeal joint, and 50 ~ and 39.3 ~ in the proximal interphalangeal joint, respectively. 3. When compared with the contralateral index fingei, the pinching power was measured at 83% in group 1, 70% in group 2 and 60% in group 3. 4. Excellent results were obtained in group 1, good results in group 2 and fair results in group 3. Accordingly, the more proximal the defect in the index finger, the less satisfactory the result obtained. 9 2000 The British Association of Plastic Surgeons Keywords: second toe, index finger transfer. The index finger is functionally and cosmetically important and its reconstruction may be considered to be essential. Reconstruction of the index finger requires tissue of similar length, shape and skin texture, good functional ability and sensation, plus a minimal donor site morbidity. There have been several methods developed for the reconstruction of the index finger such as osteoplasty with a local or distant flap. However, these methods have disadvantages, including inappropriate sensory recovery and the resorption of the transplanted bone. In 1960, Jacobson and Suarez 1 were the first to introduce vascular microsurgery, then, in 1965, Bunck et al 2 used microvascular surgery to transfer a monkey's great toe to its thumb. Since the first clinical description of great toe to finger transfer by Cobbett 3 in 1969, many reports have been published. 4-16 The second toe has also been transferred to the thumb and fingers because the second toe has a similar length, shape and skin texture to a finger. This study reports on 15 patients with index finger injuries who were treated using a second-toe transfer. Depending on the amputation level, either a partial or total second toe was transferred to the index finger. Materials and methods Second-toe transfers were performed on a total of 15 patients between March 1994 and May 1998. The defect causes included crushing injuries and amputation by machine. Stump plasty was initially performed on the injured index finger tips of six of the patients, whereas in the other nine cases the injured tips were covered with a groin flap. The patients included six males and nine females with an age range of 19-40 years. The patients were divided into three groups depending on the amputation level. Group 1 consisted of patients with index finger defects immediately proximal to, yet including, the distal interphalangeal joint, group 2 were those patients with defects from the proximal part of the distal interphalangeal joint to the distal part of the proximal interphalangeal joint and group 3 comprised patients with more proximal defects than group 2 (Fig. 1). For patients in groups 1 and 2, only a partial length of the second toe was transferred to the index finger, whereas in group 3 the transfer of the total length of the toe was required. 324

Second toe to index finger transfer 325 B Group 1 Group 2 Group 3 \ \ A Figure 1--Schematic diagram for group classification of the index finger defects. Figure 2--Schematic diagram of operative technique. (A) group 2. (B) group 3. (A: artery, V: vein, N: digital nerve, T: tendon). The course of the dorsalis pedis artery and first dorsal metatarsal artery (FDMA) was traced preoperatively using an ultrasound Doppler. The superficial foot dorsal vein to the second toe was confirmed by the naked eye and marked. The second-toe flap was designed a little larger than the defect size of the index finger. In group 1, two triangular flaps were designed on both lateral sides of the index finger to prevent any linear scar contracture and avoid the exposure of the neurovascular pedicle without skin tension during skin closure. In groups 2 and 3, triangular flaps were designed on the plantar and dorsal sides of the foot (Fig. 2). Under tourniquet control, the superficial foot dorsal vein was dissected, thereafter the dissection proceeded along the FDMA. In groups 2 and 3, the extensor digitorum longus, extensor digitorum brevis and flexor digitorum longus were all included in the secondtoe flap. In group 1, the fusion of the distal interphalangeal joint was performed in a functional position in three cases. The bone fixations were performed using K-wire in three cases from group 1, and interosseous wiring in four cases from each group. The extensor digitorum longus of the second toe was sutured to the central band of the extensor tendon of the index finger. The extensor digitorum brevis of the second toe was split into two parts and sutured to the lateral bands in order to reinforce the extensor function of the transferred second toe. The flexor digitorum longus of the second toe was sutured to the flexor digitorum profundus of the index finger at the distal palmar crease and the suture tension was adjusted to avoid any flexion deformity of the transferred second toe. The FDMA and superficial foot dorsal vein were anastomosed to either the digital artery of the ulnar side of the index finger or the common digital artery and dorsal vein of the hand. In one case, the dorsalis pedis artery and larger vein of the foot dorsum were anastomosed to the radial artery in the snuff box and dorsal vein of the hand. The two plantar digital nerves of the second toe were connected to the two digital nerves of the index finger. Immobilization was continued for 4 weeks in group 1. However, flexion and extension were initiated from the first day after operation in groups 2 and 3. The donor defect was performed by primary closure in 10 cases from groups 1 and 2, and by ray amputation in all other patients. Results A partial length of the second toe was transferred in 12 cases and the total length was transferred in three cases (Figs 3-5). All toes survived completely. The average hospitalization period was 18 days. The average followup period was 18.7 months (from 6 months to 36 months). The two-point discriminations for the normal contralateral index finger tip and second toe were 2.4 mm and 5.4 mm on average, respectively. The average two-point discriminations of the transferred second toes were 2.2 mm in group 1, 2 mm in group 2 and 2.3 mm in group 3 (Table 1). The two-point discrimination of the transferred second toe was much improved compared to that of a normal second toe and nearly the same as that of a normal index finger. The motor function recovery was evaluated by measuring the range of motion of each joint with a goniometer. The normal range of motion of contralateral index fingers was 75 ~ in the distal interphalangeal joint and 105 ~ in the proximal interphalangeal joint. In group 1, the average range of motion of the transferred toes was 43.8 ~ in the distal interphalangeal joint. Three of the distal interphalangeal joints were fused. In groups 2 and 3, the average range of motion of the transferred toes was 30 ~ and 30.7 ~ in each of the distal interphalangeal joints, and 50 ~ and 39.3 ~ in each of the proximal interphalangeal joints. The average pinching power was 83% in group 1, 70% in group 2 and 60% in group 3 compared with the normal contralateral index finger. There were several complications in the donor site with individual cases of a partial loss of the

326 British Journal of Plastic Surgery Figure 3--Case 1. (A) Preoperativeviewof the index finger tip coveredwith groin flap. (B) Two-yearpostoperativeviewshowingnearly normal length, shape and skin texture. Figure 4--Case 3. (A) Preoperativeviewof the index finger tip. (B) Two-yearpostoperativeview. grafted skin, haematoma, and infection. Two patients complained of cold intolerence in the transferred second toe. A scar contracture of the grafted skin on the reconstructed index finger developed in two cases. Secondary procedures were needed in every case such as pulp plasty to reduce the pulp volume of the transferred second toe and scar revision. Based on the above results, the final appearance and function of the reconstructed index fingers were most satisfactory in group 1. Discussion When the thumb or index finger is amputated traumatically, successful replantation is a good method to restore function and shape. In general, a single digit replantation of a Zone II injury in a non-thumb and non-index digit is inappropriate and worsens the function. However, in Asian culture the social impact of losing a finger is very significant for the patient, accordingly, replantation is extremely important.

Second toe to index finger transfer 327 Figure ~ C a s e 8. (A) Preoperative view of amputation of the index finger at distal level of the proximal interphalangeal joint. (B) Tendon of the extensor digitorum longus of the second toe sutured to the central band of extensor of the index finger. The tendon of the extensor digitorum brevis was split and sutured to the lateral bands to reinforce the extensor function. (C) Six-month postoperative view showing good shape of index finger. (D) Good postoperative pinching view. Ideally a reconstructed finger should be functionally and aesthetically acceptable plus there should be minimal d o n o r deformity. Until now, several techniques have been proposed. W h e n the defect is confined to the tip, osteoplasty plus either a cross finger flap from the middle finger d o r s u m or a thenar flap can be used. If the defect is m o r e proximal, the defect can be reconstructed by osteoplasty with a distant flap. C o m p o s i t e tissue transfer has been proposed by several authors.iv 24 Park et a124 replanted the nail and distal phalanx, and reconstructed the soft tissue defect with a cross finger flap. However, the disadvantages o f their

328 British Journal of Plastic Surgery Table 1 Case summary and classification in accordance with defect level of fingers Group Cases Sex~Age Site~Level Donor Two ROM Follow-up PD (ram) DIP PIP Pinching power(%) (months) 1 1 M/24 Lt. DIP joint Rt. 2nd toe (partial) 2.3 Fusion 86 24 2 Fl26 Rt. distal phalanx Lt. 2nd toe (partial) 2.4 Fusion 82 23 3 F/22 Rt. DIP joint Lt. 2nd toe (partial) 2.2 40 80 25 4 F/19 Lt. DIP joint Rt. 2nd toe (partial) 2.1 45 81 9 5 M/32 Lt. DIP joint Rt. 2nd toe (partial) 2.1 48 88 11 6 M/28 Rt. DIP joint Lt. 2nd toe (partial) 2.2 42 82 20 7 Fl27 Lt. DIP joint Rt. 2nd toe (partial) 2.1 Fusion 82 19 2 8 F/19 Rt. just distal of Lt. 2nd toe (partial) 2.0 30 47 67 6 PIP joint 9 Ml24 Rt. midlevel of Lt. 2rid toe (partial) 2.2 25 45 75 24 10 Fl26 Lt. midlevel of Rt. 2nd toe (partial) 2.1 35 53 73 12 11 M/28 Rt. midlevel of Lt. 2nd toe (partial) 1.8 32 55 68 19 12 M/22 Rt. midlevel of Lt. 2nd toe (partial) 1.9 28 50 67 26 3 13 F/34 Rt. midlevel of Lt. 2nd toe (total) 2.3 31 39 62 36 proximal phalanx 14 F/40 Lt. proximal level of Rt. 2nd toe (total) 2.1 28 37 63 22 proximal phalanx 15 F/26 Rt. midlevel of Lt. 2nd toe (total) 2.2 33 42 55 14 proximal phalanx PD: point discrimination; ROM: range of motion; DIP: distal interphalangeal joint; PIP: proximal interphalangeal joint. method include the resorption of the replanted bone, atrophy of the nail and difficulty in soft tissue coverage for a large area. First and second web space flaps 7,25 have been used for soft tissue defects of the index finger. In the case when the soft tissue and nail have both been lost simultaneously, either a second-toe wrap-around flap 15'26'27 or an extended wrap-around flap 28 has been used. However, a second-toe transfer can provide a good substitute for the index finger; it transfers composite tissue including a nail and a transferred second toe is very similar to a normal index finger in appearance and function. A third-toe transfer for the reconstruction of the distal phalanx of fingers also has been reported. 16 A partial length of the second toe was transferred in group 1. Cosmetically, the resulting reconstructed index fingers appeared very similar to normal index fingers. A partial length of the second toe with a tendon was transferred in group 2. Since the flexor tendon is stronger than the extensor tendon in a toe plus its phalanx is shorter than in an index finger, flexion deformities and motion limitations of the proximal interphalangeal joint will inevitably develop after second-toe transfers. Accordingly, it is essential that the tension of the extensor tendon should be greater than that of the flexor tendon after tendon suturing and the digital joint of the toe should be maintained in a full extended position. 6,m The interosseous wiring of the bone is preferred to K-wire fixation in order to promote early active exercise thereby preventing tendon adhesion. The flexion deformity of the transferred toe was reduced by the reinforcement of the extensor tendon and early exercise. The flexion deformity of the proximal interphalangeal joint was mild and the range of motion was between 45 ~ and 55 ~. The pinching power was 70% of the normal level. Foucher et al 7 and Lister et al s reported on reconstructed fingers that exhibited 38% and 15.6% of normal pinching power. The total length of the second toe was transferred in group 3. If the transferred second toe includes the metacarpophalangeal joint for more length, a flexion deformity of the proximal interphalangeal joint will inevitably develop. To overcome this problem, either the metacarpophalangeal joint was disarticulated or the bone was cut at the level of the proximal portion of the proximal phalanx. The ranges of motion of the proximal interphalangeal joint and distal interphalangeal joint of the reconstructed index were 39.3 ~ and 30.7 ~ respectively. The pinching power was 60% of the normal level and the pinching motion was good. However, the overall results were inferior to those of the patients in group 2. These results demonstrate that the partial reconstruction of the index finger with a second-toe transfer is a very useful method for cases such as groups 1 and 2. The results of the total reconstruction of the index finger using a second-toe transfer, as in group 3, were disappointing due to the inadequate length, narrow shape and limited motion of the reconstructed index finger. The two-point discrimination of the reconstructed index averaged 2.2 mm in group 1, 2 mm in group 2 and 2.3 mm in group 3. These results are similar to those of a normal index finger (2 mm on average) and much better than those of a second toe. Koshima et al, 29 Morrison et ap ~ and Buncke and Rose 31 also reported similar results. The cause of the improved sensation is unknown but is believed to be the result of greater cortical representation, cortical re-education and an increase in the peripheral receptor density. 3~ Accordingly, it would appear that the sensory recovery

Second toe to index finger transfer 329 of the reconstructed index finger is more dependent on the nature of the recipient than on the donor. Furthermore, due to the high density of the sensory end organs, the glabrous skin of the second toe is a very similar tissue to the palmar skin of the hand? 2 As a result, attention should be paid to the coaptation of analogous nerves (i.e. coapting the plantar digital nerves to the digital nerves of the index finger). It should also be noted that a vascularised nerve produces a more rapid axonal regeneration and remyelination. Therefore, the age of a patient and the ischaemic time of the toe would also seem to have an influence on sensory recovery. For rapid nerve regeneration and sensory recovery, all scar tissue over the nerve stump should be thoroughly resected and the nerve sutured without tension. In this study, the proper digital nerve of the index finger, which is a branch of the median nerve, was usually used as the recipient nerve instead of the dorsal branch of the ulnar nerve. The course of the FDMA was variable in the current study. Gilbert's 33 type I included 5 cases, type IIa - 6 and type IIb - 4. However, type III was absent in the patients in this study. Vein grafts were not performed. In groups 2 and 3, skin grafts were conducted on the connecting site of the finger and toe in order to cover the exposed soft tissue and avoid excessive pressure and exposure of the vascular pedicle. Hyperpigmentation, lateral bulging and mild scar contractures developed on the skin-grafted sites after the operations. As a result, z-plasty and scar revisions were performed as secondary procedures. Therefore, in group 1, to minimize the scar contractures, slightly larger triangular flaps were designed on both lateral sides of the second toe instead of the normal cylindrically shaped toe flaps. There was very little donor morbidity. No resorption of the reconstructed bone or nail was observed. However, two patients complained of cold intolerance. Lister et al 8 suggested that such cold intolerance is due to an inadequate volume of circulating blood or frequent vasospasm. They also recommended that reducing the ischaemic time, avoiding small sized vessels of less than 1 mm in diameter, multiple anastomoses and stopping smoking all help in preventing cold intolerance. In conclusion, excellent results were obtained in group 1, good results in group 2 and fair results in group 3. Accordingly, the more proximal the defect in the index finger, the less satisfactory the result obtained. References 1. Jacobson JH, Suarez EL. Microsurgery in anastomosis of small vessels. 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Reconstruction of the hand with free microneurovascular toe-to-hand transfer: experience with 54 toe transfers. Plast Reconstr Surg 1983; 71: 37~86. 9. Wei FC, Colony LH. Microsurgical reconstruction of opposable digits in mutilating hand injuries. Clin Plast Surg 1989; 16: 491-504. 10. Gu YD, Zhang GM, Cheng DS, Yan JG, Chen XM. Free toe transfer for thumb and finger reconstruction in 300 cases. Plast Reconstr Surg 1993; 91: 693-702. 11. Byun JS, Park JW, Baik BS. Reconstruction of fingers by microvascular toe transfer. Korean J Plast Reconstr Surg 1993; 20: 394-409. 12. Mitz V. Second toe to thumb transfer with extensor digitorum brevis opponensplasty. Ann Plast Surg 1986; 17: 259-62. 13. Koshima I, Moriguchi T, Soeda S, Hamanaka T, Umeda N. Free second toe transfer for reconstruction of the distal phalanx of the fingers. Br J Plast Surg 1991; 44: 456-8. 14. Foucher G, Moss ALH. 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330 British Journal of Plastic Surgery The Authors Byung Chae Cho MD, Associate Professor Jin Suk Byun MD, Attending Staff Jae Woo Park MD, Instructor Bong Son Baik MD, Professor and Director Department of Plastic and Reconstructive Surgery Kyungpook National University Hospital, Samduk 2 ga, 50, Taegu 700-721, Korea. Dong Hoon Lee MD, Instructor Department of Plastic and Reconstructive Surgery, Choongnam -National University Hospital, Taejeon, Korea. Correspondence to Byung Chae Cho. Paper received 22 September 1998. Accepted 1 March 2000, after revision.