Rev esp cir ort op t raumat ol.

2011;55(4):257-262

Revista Española de Cirugía

Ortopédica y Traumatología

www.elsevier.es/ rot

ORIGINAL ARTICLE

Report on 250 consecutive toe to inger transplants. Indications,

results, failures, and new applications
Francisco del Piñal, * Francisco Javier García-Bernal, Carlos Thams,
Alexis Studer, Javier Regalado

Inst it ut o de Cirugía Plást ica y de la Mano Dr. Piñal y Asociados, Hospit al Mut ua Mont añesa y Práct ica Privada,
Sant ander, Spain

Received December 9, 2010; accept ed March 24, 2011

KEYWORDS Abstract
Amput at ion; Purpose: Toe-t o-hand t ransfers are an essent ial part of hand rehabilit at ion aft er loss of a
Microsurgery; inger. Despite this, the likelihood of failure and the hypothetical morbidity in the donor
Toe-t o-han area, made t his procedure not very popular among surgeons. The purpose of t his paper
is t o present our clinical experience, highlight ing t he pit falls and t he new indicat ions.
Mat erial and met hods: Bet ween February 1995-January 2010 we performed 250 t oe-t o-
hand transfers for inger amputations. In metacarpal hands (23 cases) we transferred the
hallux from one foot and the 2nd and 3rd from the other, to achieve a three-ingered
(t ripod) grasp. The rest of t he pat ient s had mult i-digit , simple or part ial amput at ions. In 69
the thumb was reconstructed and the rest of transfers were for inger reconstructions.
Result s: Re-operat ion rat e due t o acut e ischaemia was 16%(10%int raoperat ive) and t he
overall success rate was 98.8% (3 failures). There was no partial necrosis in any case.
Regarding t he donor side, one pat ient was operat ed on due t o a painful neuroma; t he rest
did not have complaint s in t he donor area.
Conclusions: In our experience t oe-t o hand t ransfers are a safe and reliable met hod t o
rehabilit at e severe hand inj uries. Donor sit e morbidit y is direct ly relat ed t o t he number
of t oes harvest ed, and is well-t olerat ed by t he pat ient s, especially in severe inj uries.
© 2010 SECOT. Published by Elsevier España, S.L. All right s reserved.

PALABRAS CLAVE Informe sobre el trasplante de 250 dedos del pie a la mano consecutivos.
Amput ación; Indicaciones, resultados, fracasos y nuevas aplicaciones
Microcirugía;
Dedo del pie a la mano Resumen
Propósit o: Las t ransferencias de dedos del pie const it uyen un arma fundament al en la
rehabilit ación de las lesiones de mano. Sin embargo, no gozan de mucha popularidad

* Corresponding aut hor.

E-mail: drpinal@ono.com (F. del Piñal).

1888-4415/ $ - see front mat t er © 2010 SECOT. Published by Elsevier España, S.L. All right s reserved.
258 F. del Piñal et al

dada la posibilidad de fracaso y por las hipot ét icas secuelas en la zona donant e. Presen-
t amos nuest ra experiencia clínica, haciendo especial hincapié en las complicaciones y las
nuevas aplicaciones.
Mat erial y mét odos: En el periodo febrero de 1995 - enero de 2010 hemos realizado
250 t ransferencias de dedos del pie para amput aciones de t odos o part e de los dedos. En
las amputaciones de todos los dedos (23 casos) se trasplantaron el hallux de un pie y el
2.° y 3.er dedos del pie cont ralat eral para lograr una pinza t rípode. El rest o de los casos
corresponden a amput aciones mult idigit ales, simples o parciales de dedos, siendo 69
casos pulgares y el rest o, dedos t rifalángicos.
Result ados: La t asa de reint ervención por isquemia aguda fue del 16%(10%int raoperat o-
ria), con una supervivencia inal del 98,8% (3 fracasos) tras la revisión quirúrgica. No hubo
ninguna necrosis parcial. Respect o a la zona donant e, un pacient e fue int ervenido por
presentar un neuroma; el resto no reirió ningún tipo de molestias a la marcha, en el
seguimient o a largo plazo.
Conclusiones: En nuest ra experiencia, las t ransferencias de dedos del pie son un mét odo
seguro en la reconst rucción de lesiones graves de la mano. La secuela del pie es propor-
cional a la cant idad de dedos que se t omen, y es bien acept ada por el pacient e, en espe-
cial en las graves lesiones.
© 2010 SECOT. Publicado por Elsevier España, S.L. Todos los derechos reservados.

Introduction

Toe t ransfers have been a rout ine pract ice for more t han
40 years. 1 Alt hough init ially it s use was limit ed t o t he t humb,
it came t o be more widely used as survival rat es improved.
So much so t hat , nowadays, t hese t ransfers are indicat ed in
bot h reconst ruct ion of severe inj uries (for example, mult i-
digit amput at ions) and in more minor inj uries (for example,
part ial t humb amput at ions) where t he t reat ment obj ect ive
is, essent ially, rest it ut io ad int egrum. 2
Our purpose is t o present an updat e on t he indicat ions,
result s, and donor sit e sequelae based on our experience
wit h 250 t ransfers.

Materials and methods

From February 1995 t o January 2010, we performed 250

toe-to-hand transfers. The irst author was involved in all
cases, wit hout except ion.
Alt hough t here were paediat ric and elderly pat ient s in
our series, our case load consist ed of labourers, primarily,
and the mean age for our series was 37.6 years (range 2-64).
Certain conditions such as age, smoking, hypercoagulable
st at es, and previous t rauma in t he donor sit e area are
unfavourable fact ors, but t hese do not cont raindicat e
t ransplant as long as it is t hought t hat t he pat ient may
beneit from the surgery. It is contraindicated, however, if
t he pat ient is in poor general condit ion or has a severe,
art erit is oblit erans-t ype of art eriopat hy.
Fort y-nine pat ient s received 2 t oes, and 27 pat ient s
received 3 toes. In 38 cases, it was necessary to combine
t he t oe-t o-hand t ransfers wit h anot her t ype of microsurgical Figure 1 A) 28-year-old pat ient wit h mult i-digit amput at ion
t issue t ransfer, eit her during t he same procedure or prior t o due t o avulsion and inj ury at various levels, which made it
it , because of coverage problems. impossible to reimplant 2 of the ingers. A heterotopic
Of t he 250 cases, 148 t ransfers were done early (less t han reimplantation of the 3rd t o t he 2nd posit ion was performed on
1 week) (ig. 1), and 43 were done prior to 1 month. The an emergency basis. One week later, patient underwent an
remaining 59 were performed late (range: 5 weeks to aest het ic amput at ion of t he t hird ray and t he t ransfer of a
32 years). 2nd t oe t o t he 4t h position. B) Results at 3 months.
Report on 250 consecutive toe to inger transplants. Indications, results, failures, and new applications 259

The elevat ion t echnique has already been described, 3-5

but we would like to stress the importance of skeletonizing
t he art eries and veins t o reduce t he amount of fat and t he
volume of t he pedicle t ransferred t o t he hand. This
precludes the need for skin grafts or laps as a means of
itting the excess tissue onto the hand, and because better
aest het ic result s are achieved in a single procedure, it also
obviat es t he need of a second surgery for remodelling. Wit h
experience, our preference for donor vessels has changed
from the dorsal artery of the foot or the irst dorsal
int ermet at arsal art ery and t he saphenous vein, which was
our initial practice, to the tibial and/or ibular digital artery
and a dorsal subcut aneous vein from t he commissure of t he
inger, currently. This has enabled us to shorten the total
surgery time to about 3 hours, currently, and to minimize
foot morbidit y. There is a downside t o it in t hat t he vessels
for t he microsurgery are of smaller calibre.
While t he t oe is being adapt ed t o t he hand, anot her
surgical t eam closes t he result ing defect in t he donor sit e
area. They use different t echniques for t his depending on
t he amount of t issue harvest ed from t he foot . Defect s
result ing from t he t ransfer of soft t issue from a t oe
(hemipulp or neurocut aneous6) are reconst ruct ed using Figure 2 A-B) Bilat eral met acarpal hand referred 5 mont hs
neurovascular island laps or skin grafts. On the other hand, aft er inj ury. C-D) On t he left hand, t he big t oe was t ransplant ed
if a phalanx or a j oint has been harvest ed, we preserve t he t o t he t humb posit ion, and t he st umps of t he 2nd and
t oe by doing an art hroplast y or creat ing a syndact yly. 7,8 3rd met acarpals were resect ed t o provide a good commissure.
If a 2nd toe has been harvested, an aesthetic amputation of The right hand was reconst ruct ed by t ransferring a microvascular
the ray is done, with resection of the metatarsal and closure lateral thigh lap and a tandem lap of the 2nd and 3rd t oes in t he
of the space between the 1st and 3rd metatarsal with 2 Kirschner same surgical procedure. E) Case 2 donor sit e area 4 years aft er
wires for 5 weeks. Transfers of the big toe are reconstructed surgery. The patient reports walking at least 10 km every day.
through transfer of the 2nd toe to the 1st toe position. 9 In the Not e t hat pat ient wears regular shoes.
event of a combined, tandem-type transfer of the 2nd and
3rd toes, we try to preserve the metatarsophalangeal j oints to
prevent dificulties with ambulation.10 We recommend to pat ient was int egrat ed int o a new j ob, and he has required
patients that they avoid weight-bearing for 6 weeks. Following no furt her t reat ment .
surgery, patients remained in the hospital for a mean period of We have had some problems wit h primary wound healing
6 days on a continuous heparin infusion, and they were in t he donor sit e area, above all in t hose cases where t here
monitored with an acoustic Doppler sensor. was an associated fasciocutaneous lap. These cases closed
by second int ent ion.
One pat ient wit h hypercoagulabilit y due t o prot ein S
Results deiciency developed a deep vein thrombosis in the donor
leg, 10 days aft er t he surgery when he was already at home
In 84%of t he cases, immediat e revascularisat ion of t he t oes and despit e low-molecular-weight heparin t herapy. Aft er
was achieved upon removing t he vascular clamps, wit h no warfarin t herapy was inst it ut ed, progress was favourable
furt her complicat ions. In 16% of t he cases, t he anast omosis both for the patient and for the transferred irst toe.
had t o be revised: in t he same surgical procedure, aft er
removing t he clamps (10%) or in a separat e procedure aft er
patient was returned to the loor (6%). On 3 occasions, Discussion
complet e necrosis occurred (overall survival: 98.8%) despit e
all at t empt s t o resolve it (reanast omosis, int erposit ion graft s, The t oes enable hand funct ion t o be improved in proport ion
and the like). There were no cases of partial necrosis. to the existing deicit. In cases of multi-digit amputations or
Regarding morbidit y of t he donor sit e area, we had met acarpal hands, t hey are used t o achieve a simple or
2 cases of medium-term discomfort with walking. One t ripod grip, 4,10,11 while in less serious cases, t hey cont ribut e
pat ient , who had undergone t ransfer of a 2nd t oe and a t o a pract ically t ot al anat omical and funct ional recovery. 2,12
contralateral big toe, reported discomfort with walking due
t o a neuroma in t he st ump of a collat eral nerve, which was Donor site area
resolved by t ransposing it . Anot her pat ient , on whom a
tandem lap had been transferred (2nd and 3rd t oes) for a Bot h t he aest het ic and funct ional out come in t he foot
met acarpal hand reconst ruct ion, report ed pain in one of his depends upon t he defect t o be reconst ruct ed. Minor lesions
feet when walking; this persisted for 2 years, despite are reconst ruct ed almost anat omically, wit h minimal
ort hot ic t reat ment . The discomfort disappeared when t he sequelae in t he foot , while in t he case of mult i-digit
260
Figure 3 Outcome for the donor site area of a irst toe used in
t humb reconst ruct ion, wit h and wit hout t ransposit ion of t he
t oe.
amput at ions where several t oes are harvest ed, t here are
more sequelae in the donor site area (ig. 2). When it is a
met acarpal hand, 13 for example, t he big t oe is harvest ed
from one foot and a lap combining the 2nd and 3rd t oes from
t he cont ralat eral foot . 14 In t erms of morbidit y in t he donor
sit e area, various st udies have shown t hat gait is not
impaired if t he base of t he proximal phalanx of t he big t oe
is left or if no more t han 2 t oes are harvest ed. 15,16
Our result s agree wit h t hose of ot her series3,17-20 in which
problems wit h ambulat ion are pract ically non-exist ent . In
reviewing our result s wit h t ransfers of t he 2nd and 3rd t oes
combined–one of t he most serious assault s on t he donor sit e
area t o which t he foot is subj ect ed–not one pat ient report ed
any funct ional sequelae wit h regard t o ambulat ion. 4 Of t he
remaining pat ient s (simple t oe t ransfer), 1 pat ient required
anot her surgery t o t ranspose a neuroma, and anot her
pat ient report ed discomfort t hat improved wit h using
orthotics, pain after walking several kilometres, despite
non-weight -bearing insoles, met at arsal bars, et c.
Resect ion of t he big t oe result ed in a very not iceable
aesthetic law if the stump was simply closed. To mitigate this
defect, we transposed the second toe to the irst position and
increased it s volume using a t ibial cut aneous int erposit ion
lap (ig. 3).9 We followed a t ot al of 17 pat ient s over a
minimum of 2 years. Evaluat ion of funct ional sequelae in t he
foot using a Visual Analogue Scale (VAS) (no limit at ion, no
pain=0…incapacit at ing limit at ion, int olerable pain=10)
result ed in a mean of 2.4, and for aest het ic sequelae
(normal=0…severe deformity=10), a mean of 3.6. Evaluation
of sequelae in t he foot using t he AOFAS scale result ed in a
mean of 89.4. 21
Re-operations and failures
One of t he primary reasons for discouragement among
surgeons who do this type of procedure is the risk of
microvascular complicat ions. Aft er dissect ion and wit h t he
t oe st ill connect ed t o it s vessels in t he foot , it is not
F. del Piñal et al
uncommon for it to take a few minutes for the toe to be
reperfused, especially when t he donor vessels are t he digit al
art eries. This spasm normally subsides wit h t he passage of
t ime and t he applicat ion of local heat and/ or a t opical
spasmolyt ic agent . Much more rarely, t he t oe remains t ot ally
ischaemic on t he foot following release of t he ischaemia cuff
and never becomes reperfused, despit e t he passage of t ime
and microsurgical explorat ion (revision of possible art ery
lesions, advent icect omy, et c.). In our experience, t his t ype
of complicat ion (12 cases) was due t o hypert rophy of t he
digit al art ery t unica media, which almost occluded it
(10 cases), or embolism secondary t o art eriosclerosis
(2 cases). 22 Our init ial hypot hesis t o explain t hese ischaemic
episodes in t he foot point ed t oward art erial hypert ension as
t he causal mechanism because t hey occurred in pat ient s who
were over 50 years of age. This suspicion was reinforced by
the anatomical pathology indings of arterial occlusion due to
hypert rophy of t he t unica media. However, we have recent ly
seen a similar pict ure in a group of young, at hlet ic pat ient s
(a marat hon runner, among ot hers) who do not have art erial
hypertension. At the present time, we are looking into the
hypot hesis t hat repeat ed t rauma may be anot her fact or in
t he appearance of t his problem and t hat hypert rophy of t he
t unica media could be of mult i-fact orial origin. This
complicat ion may be t he cause of inexplicable failures wit h
t his t echnique and, worse, cannot be predict ed before t he
foot is dissect ed. The way t o resolve t he problem is out side
the scope of this general article. Sufice it to say, however,
that this is a major challenge for a group skilled in microsurgery
and t hat it forces us t o do bypasses and/ or anast omoses wit h
arteries of less than 0.3 mm (ig. 4) because, for some
unknown reason, the more distal vessels are usually healthy.
In our experience wit h t his complicat ion (12 cases), we were
able t o resolve 11 of t hem t hrough complex bypasses, and/ or
t hey required anast omosis of vessels of up t o 0.5 mm. The
ot her case was one of t he failures in t he series.
With regard to the failures (3/250), 1 of them was due to
hypoperfusion in t he foot in a pat ient wit h severe
art eriosclerosis (ment ioned above). The second failure was
Figure 4 Rescue of an ischaemic t oe due t o hypert rophy of
t he t unica media in a young pat ient . The t oe was revascularised
via a bypass to the ibular digital artery at the DIP crease of the
2nd toe (artery diameter approximately 0.3 mm).
Report on 250 consecutive toe to inger transplants. Indications, results, failures, and new applications 261

Figure 5 A) Amput at ion of t humb at t he level of t he t rapezio-met acarpal-phalangeal j oint . B) Simult aneous t ransfer of a t oe plus
a microvascular gracilis muscle lap for coverage. C) Final result.

relat ed t o a Buerger vasculopat hy, and t he t hird was due t o
poor post -operat ive management t hat made revision and
early rescue impossible.
Because of our experience, enabling us t o short en t he
surgery t ime and achieve great er reliabilit y wit h t his t ype of
t ransfer, we have expanded t he indicat ions along 2 lines: in
complex reconst ruct ions and in “ minor” lesions. In mult i-
digit amput at ions, where t here is t ypically a loss of associat ed
soft t issue, we perform ot her microsurgical t issue t ransfers
along wit h t he t oe t ransfer in a single surgical procedure.
This reduces rehabilit at ion t ime for t he hand and precludes
other surgical procedures on healed areas (ig. 5).
The ot her line of int ervent ion has been t he so-called
mini-t ransfers: t ransfers of vascularised phalanges,

Figure 6 A) Amputation of distal thumb at the interphalangeal joint. B) Big toe modiied per the Wei technique (trimmed toe).
C-E) Result .
262
vascularised digit al nerves, and dist al t oe reconst ruct ions.
Generally speaking, these mini-transfers are technically
demanding in t hat t hey require reduct ion of t he bone,
adapt at ion of t he soft t issues, and anast omoses wit h vessels
of 0.5-0.8 mm. On t he ot her hand, morbidit y in t he foot is
minimal, and t hese mini-t ransfers enable hand anat omy
and function to be almost fully recovered (ig. 6).
Conclusions
The t oes enable funct ion t o be improved in a t raumat ised
hand. The obj ect ives will vary depending on t he severit y of
t he inj ury (t ripod grip or anat omical reconst ruct ion), and
morbidit y in t he donor sit e area will vary depending on t he
amount of t issue harvest ed from t he foot . This surgical
procedure does not involve any drawbacks in terms of
ambulat ion.
Evidence level
Evidence level IV.
Protection of human and animal subjects
The aut hors declare t hat no experiment s were performed
on humans or animals for t his invest igat ion.
Conidentiality of data
The aut hors will declare t hat t hey have followed t he
protocols of their work centre on the publication of patient
dat a and t hat all t he pat ient s included in t he st udy have
received suficient information and have given their
informed consent in writ ing t o part icipat e in t hat st udy.
Right to privacy and informed consent
The aut hors declare t hat no pat ient dat a appears in t his
art icle.
Conlict of interest
The authors have no conlict of interest to declare.
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