This paper presents a large retrospective series of remarkable simultaneous double second toe transfers over a 20-year period (1984-2003). One hundred forty patients with intact functional thumbs were treated for a variety of combined digital defects. The most common indications were absent index and middle fingers (n=90) or middle and ring fingers (n=49). Indications for the procedure were intact thumbs with absent tripod pinch, tripod pinch and improved cosmetic appearance in patients with intact index fingers, and amputation distal to the level of the web space. Only two patients were children with congenital anomalies. Roughly 50% of the patients underwent surgery at the time of injury for primary treatment of traumatic wounds. All donor sites were closed primarily. Two teams were used for simultaneous recipient and donor site dissection, limiting operative time to an average of 11 hrs, 25 min. Twenty six of 280 toes were re-explored for ischemia, and only three were lost. Two flexor tendon ruptures were successfully repaired. Secondary surgery was performed in the majority (98/104) of patients to improve functional and cosmetic results. Rehabilitation consisted of early passive motion at three days, with eight weeks of total rehabilitation to restore ADL's and gradual vocational rehabilitation thereafter.
The authors state that, "although tripod chuck pinch is sufficient for basic functions, restoration of the complete digital arcade not only enhances the cosmetic appearance but also provides more effective and powerful grasping ability." Although one cannot argue with the issue of improved cosmetic appearance with restoration of a five-fingered hand, they did not report on the results of grip strength or pinch strength testing in these patients, and therefore the issue of improved grasp is not really answered. Comparison of strength testing in this cohort with a similarly matched group of patients with single digital transfers and incomplete digital arcades, such as index ray amputations, would be extremely useful in determining the true effect of restoring complete digital arcades in patients with multiple amputations. Although this highly experienced team was able to complete the double simultaneous transfers in a remarkably short operative time, this is not likely to be reproducible in most centers with less experienced teams. Thus, the additional surgical morbidity may detract somewhat from the outstanding results seen here and the usefulness of this approach in routine trauma care.
Plastic & Reconstructive Surgery