Toe transfer surgery outperforms replantation in hand function recovery

For patients with amputations affecting the hand, toe transfer surgery provides an alternative to replanting the amputated digits and may lead to greater improvement in hand function and other key outcomes, reports a study in the August issue of Plastic and Reconstructive Surgery^®, the official medical journal of the American Society of Plastic Surgeons (ASPS). The journal is published in the Lippincott portfolio by Wolters Kluwer.

Our study provides the first evidence that toe transfer surgery provides better long-term hand function compared to attempted replantation of the amputated fingers. The findings challenge current approaches to emergency replantation surgery after digital amputations."

Fu-Chan Wei, MD, of Chang Gung Memorial Hospital, Taipei, Taiwan

Toe transfer versus finger replantation: New data on patient-reported outcomes

Amputations of the fingers and thumb are common injuries, affecting about 45,000 people per year in the United States alone. Digit amputations can leave patients with years of disability, especially if the thumb is lost. Emergency replantation of the amputated digit is the current standard of treatment but is sometimes impossible or unsuccessful.

Toe transfer surgery – using one or more of the patients' toes to replace the amputated digits – is a potential alternative to replantation. While toe transfer surgery is not a new procedure, few studies have evaluated its impact on hand function and other patient-reported outcomes.

Dr. Wei and coauthor Steven Lo, MD, of Canniesburn Plastic Surgery Unit, Glasgow, Scotland, analyzed long-term outcomes of 126 toe transfer procedures in 75 patients after digital amputation. Hand function and other patient-reported outcomes were compared to those of 96 replantation procedures in 52 patients. All patients were treated at Dr. Wei's hospital; outcomes were assessed at least five years after surgery.

Data support toe transfer as 'a viable alternative' to replantation

On the validated Michigan Hand Questionnaire, hand function was significantly better for patients undergoing toe transfer, compared to replantation. The difference in favor of toe transfer was substantial, with hand function scores about three times higher than the benefit considered clinically important. The more severe the injury, the greater the magnitude of improvement after toe transfer surgery.

Patients in the toe transfer group also had greater improvement in physical health-related quality of life, assessed using the standard SF-36 score. Foot function after toe transfer surgery was comparable to that in the general population.

The researchers performed physical assessments to evaluate the most important factors affecting hand function outcomes. Hand range of motion, tripod pinch (three-finger grip, as in holding a pencil), and moving two-point discrimination (a measure of nerve sensation) were predictors of better hand function after toe transfer. Higher overall physical and mental health scores were also associated with improved hand function.

Previous studies of toe transfer surgery have consistently yielded high surgical success rates. However, these studies have not included validated assessments of hand function. No evidence-based guidelines have been developed to help guide the decision to perform toe transfer versus attempted replantation for patients with amputations of the fingers and/or thumbs.

"These data provide the first evidence for the potential functional superiority of toe transfers over replantation in digital amputation using one of the largest validated outcome datasets of toe transfers to date," Drs. Wei and Lo write. They believe their findings challenge the assumption that emergency replantation should always be the "gold standard" after digital amputation, and suggest that toe transfer can be considered "a viable alternative" for some patients. Furthermore, this study suggests that integrating toe transfers into national healthcare frameworks has the potential to positively address one of the single largest causes of disability worldwide.