Evolving indications

The indications for toe transfers for congenital differences of the hand continue to evolve as surgeons become more comfortable with microsurgical techniques in young children. In general, toe-to-hand transfer has been performed for congenital absence of the thumb, transverse arrest, longitudinal deficiency, congenital constriction ring syndrome, and symbrachydactyly [16]. The distinction between the different etiologies is important, because the anomaly often defines the abnormal anatomy in the hand. In general, a child may have an inadequate thumb (Figs. 1 and 2), inadequate fingers (Figs. 3 and 4), or an inadequate thumb and fingers. The ultimate goal is to establish a prehension pattern with sensate pinch (side-to-side pinch, tripod pinch, large-object grasp, and use as a helper hand) [29]. Although the cosmetic appearance of the hand is important, function remains the primary goal.

When reconstructing an adactylous hand, most surgeons plan a two-stage procedure in which a new thumb is reconstructed first followed by an ulnar digit. Although great and second toes have been used for thumb hypoplasia, most hand surgeons still consider pollicization to be the best option [6,8,9,30]. The exception to this is in

Fig. 1. (A, B) Absence of the thumb, index, and middle fingers due to congenital constriction ring syndrome in a 3-year-old child. (C) She underwent a second toe-to-thumb transfer and, at the same time, ray amputation of the index finger metacarpal, which was used as a bone graft to lengthen the proximal phalanx of the middle finger. (D, E) Appearance and function of the thumb 2 years postoperatively.

congenital constriction ring syndrome where the thenar muscles are preserved (see Fig. 1), in which a better result can be expected with toe-to-thumb transfer [31]. Ulnar deficiencies of the hand are re-constructable with a toe transfer to provide a post for grasp (see Figs. 3 and 4). The location into which the toe is transferred depends on the anatomy. Most surgeons recommend the transfer of a single toe in these cases into the ring or middle finger position. Potentially, up to two toes can be transferred per hand. In bilateral congenital hand differences, the donor sites may be limited given the positive association between severe bilateral hand defects and foot defects.

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