History of thumb reconstruction

Non-microsurgical thumb reconstruction remains a viable alternative in some cases. Pollici-zation [1,2] is probably the method of choice for thumb reconstruction in congenital absence or longitudinal loss of the thumb. However, great toe or second toe transplantation can be performed for reconstruction of congenital anomalies of the thumb (ie, amniotic band syndrome) because recipient structures are present. The concept of microsurgical toe transplantation became a viable alternative when Buncke and colleagues [3] in 1966 reported the first toe-to-hand transplantation in a rhesus monkey. He fashioned the operation after Nicoladoni's [4] two-staged toe transfer via

* Corresponding author.

E-mail address: [email protected] (G.M. Buncke).

a cross toe-to-thumb flap. The first stage pedicled the second toe to the thumb position to allow vascular in-growth and during the second stage the pedicle was divided from the foot. Unfortunately, this technique did not become readily accepted because of positioning, immobilization, and functional outcome. However, using microvascular techniques, Buncke [3] performed a singlestage transfer of the great toe to the thumb in the rhesus monkey. Soon after that, Cobbett [5] performed the first toe-to-thumb transplant in a human. Buncke and colleagues [6] then successfully performed the second great toe-to-thumb transplant, the first in the United States. This set the stage for an explosion in microsurgical tissue transplantation.

The second-toe transplant has received attention for thumb reconstruction, particularly in the Asian cultures, for its reduced donor site morbidity, the size of the great toe on the hand, and for cultural considerations. Limitations to second-toe transplant include a small bulbous-appearing pulp, an metacarpophalangeal joint (MCPJ) that tends to hyperextend, and a distal interphalangeal joint and proximal interphalangeal joint that tend toward hyperflexion. In comparison to the great toe, power grip is decreased. The anatomy of the second toe is more compatible and more suited for digital reconstruction.

Donor site considerations for the loss of the great toe have inspired some surgeons to develop the wraparound flap as described by Morrison [7] and Urbaniak [8]; however, because of the loss of its soft tissue attachments to the underlying phalanx, limitations exist with the loss of critical nail plate and pulp as a unified structure. Foucher and colleagues [9] described using the wraparound flap for the thumb in combination with a second-toe neurovascular flap to close the great-toe donor site. These techniques all have a place in the armamentarium of thumb reconstruction and have become ingrained into different institutions as their standard. Given the multiple options and refinements available to reconstruct the thumb, controversies will continue. Based on our experience, the great-toe transplant is our first choice for thumb reconstruction despite the modest donor site morbidity [10,11].

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