Toe-to-hand transfer

1. For congenital hand differences, pooled data show similar success rates for non-vascularised and vascularised toe transfers.

False

Meyers' systematic review of 40 studies found success in 98.6% of vascularised transfers against 86.8% of non-vascularised transfers (P < 0.001). Resorption caused most complications after non-vascularised transfer, which also needed more secondary procedures; vascular complications followed 6.8% of vascularised transfers, most salvaged by reoperation.

• Meyers A, Bassiri Gharb B, Rampazzo A. A Systematic Review of Vascularized and Nonvascularized Toe Transfer for Reconstruction of Congenital Hand Differences. Plast Reconstr Surg. 2023;151(6):1256-1273. PMID 36728793

2. In children, the growth plates of a microsurgically (vascularised) transferred toe usually remain open, and the transferred digit continues to grow.

True

Chang's radiographic review of 23 paediatric toe-to-hand transfers found open epiphyseal plates in 27 of 28 phalanges, increased bony length in 9 of 10 transfers followed for more than 6 months, and length equal to the contralateral control toe in the four patients compared. Wei's series of children with traumatic amputations also found growth of the transferred phalanges similar to that of non-transferred ones. These data apply to vascularised transfers.

• Chang J, Jones NF. Radiographic analysis of growth in pediatric microsurgical toe-to-hand transfers. Plast Reconstr Surg. 2002;109(2):576-82. PMID 11818839
• Wei FC, el-Gammal TA, Chen HC, Chuang DC, Chiang YC, Chen SH. Toe-to-hand transfer for traumatic digital amputations in children and adolescents. Plast Reconstr Surg. 1997;100(3):605-9. PMID 9283557

3. Pooled data show the lowest rate of functional donor-site morbidity after great toe transfer.

False

Sosin's systematic review of 802 digit transfers found gait impairment after 23.7% overall, with functional morbidity rates of 21.8% after great toe, 14.5% after second toe and 23% after other toe transfers. Donor-site reoperation was, however, least frequent after great toe transfer (4.5% against 16.6% for second toe), and rigorous biomechanical evaluation of the donor foot was lacking.

• Sosin M, Lin CH, Steinberg J, Hammond ER, Poysophon P, Iorio ML, et al.. Functional Donor Site Morbidity After Vascularized Toe Transfer Procedures: A Review of the Literature and Biomechanical Consideration for Surgical Site Selection. Ann Plast Surg. 2016;76(6):735-42. PMID 26207553

4. In a single-surgeon comparison, immediate toe-to-hand transfer after acute hand injury had significantly higher rates of emergency re-exploration and infection than elective transfer.

False

Woo compared 25 immediate with 65 elective toe-to-hand transfers by the same surgeon: the rates of emergency re-exploration and postoperative infection did not differ significantly, and immediate transfer shortened convalescence. Satisfaction with the reconstructed thumb was lower than after elective reconstruction, and the appearance of the great toe donor site was mostly unsatisfactory. The comparison is small and retrospective.

• Woo SH, Kim JS, Seul JH. Immediate toe-to-hand transfer in acute hand injuries: overall results, compared with results for elective cases. Plast Reconstr Surg. 2004;113(3):882-92. PMID 15108880

5. In a multivariate analysis of 363 toe-to-hand transfers, postoperative wound infection was the strongest independent risk factor for re-exploration.

True

Lin reviewed 363 single toe transfers: 64 toes needed re-exploration, mostly for arterial spasm or thrombosis, and the overall success rate was 98.1%. Postoperative wound infection (adjusted odds ratio 12.6), metacarpal hand injury and preceding flap coverage were independently associated with re-exploration.

• Lin YT, Su ST, Lo S, Hu CH, Lin CH, Wei FC. Risk factors for reexploration in toe-to-hand transfer: a multivariate analysis of 363 cases. Plast Reconstr Surg. 2015;135(2):501-506. PMID 25357159