Pediatric Toe to Hand Transfers

History

  • O’Brien et al. and May et al. published initial case reports of toe-to-hand operations for children in 1978 and 1981.
  • In 1988, Lister presented a series of 12 second-toe transfers in children and established that microsurgical toe transfer could be performed as early as 10 months of age
  • Indications have expanded for congenital malformations, and success rates of pediatric microsurgical transfers have approached results in adult cases.
  • growth potential is preserved after toe-to-hand transfer in children (PRS Feb 2002)

Technique

  • second toe transfer is preferred in pediatric cases;
  • contralateral foot is preferred for a second toe-to-thumb transfer because the branch from the first dorsal metatarsal artery runs medial to the second toe. Allows an easy anastomosis to the snuffbox radial artery on the dorsum of the hand.
  • great toe transfers when the feet are abnormal or when the great toe is to be amputated for other reasons.
  • ipsilateral great toe is preferred for similar reasons. A natural lateral tilt places the toe in opposition, and the donor skin flaps are better arranged.
  • hand dissection is performed first to ensure adequate vessels, nerves, and tendons.
  • Foot dissection begins with preoperative marking of the dorsal arterial and venous systems.
  • It is critical to evaluate both the dorsal and plantar arterial systems before ligation.
  • In some instances, the first dorsal metatarsal artery branch to the second toe may be extremely small, and the plantar digital artery may then be traced proximally and used for vascular anastomosis.
  • metatarsal osteotomy is performed proximally in a ray resection fashion.
  • The toe is left attached only by the artery and vein to assess flow and minimize ischemia time. Once the proximal structures in the hand are prepared, the toe vessels are ligated.
  • If the metatarsophalangeal joint is included in the transfer, the fixation is angled in a slightly flexed position to counter the tendency for hyperextension at this joint.
  • To compensate for the natural flexion at the distal and proximal interphalangeal joints of the toe, a longitudinal Kirschner wire is placed temporarily to keep these joints in extension. In addition, the extensor tendon is repaired with tension.
  • Any skin deficit is covered with full-thickness skin grafts harvested from the groin.
  • Pediatric pulse oximeter is carefully placed on the transferred toe to monitor the oxygen saturation and pulse rate