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Extreme Thumb Losses: Reconstructive Strategies

del Piñal, Francisco M.D., Dr. Med.

Plastic and Reconstructive Surgery: September 2019 - Volume 144 - Issue 3 - p 665-677
doi: 10.1097/PRS.0000000000005983
Hand/Peripheral Nerve: Original Articles
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Background: Historically, complex amputations of the thumb have been managed in two stages and often require additional soft-tissue and tendon transfer for successful outcomes. This article provides several novel strategies to address these problems in a single stage using existing muscles, immediate free tissue transfer, and toe transfer.

Methods: From a personal experience of 482 toe transfers, 24 cases were performed to reconstruct extreme thumb losses. All thumbs were reconstructed in one stage. In only one case, the thumb was reconstructed with a second toe transfer; the remainder had a great toe (or a part of it) used for reconstruction. Suture, advancement, or tendon transfers were performed in all to restore intrinsic muscle function. In 19 cases, the web needed to be resurfaced with free (n = 18) or local (n = 1) flaps.

Results: All toes and flaps survived. Three patients required a secondary adductorplasty. Six of the seven patients with a metacarpal hand were able to perform tripod pinch. The rest had an average Kapandji opposition score of 7.5. Patients rated their functional and cosmetic result with a visual analogue scale score (ranging from 0 to 10) of 8.5 and 8.4, respectively.

Conclusions: In proximal thumb amputations, the surgeon should pay attention not only to the obvious thumb loss but also to the first web and the thenar muscles. The author recommends abandoning the standard approach of a pedicled groin flap followed by a toe. Otherwise, the thenar muscles become useless, the first metacarpal contracts, and the need for tendon transfers skyrockets. Further studies are required to compare the outcomes of these results to those of more classic transfers.

CLINICAL QUESTION/LEVEL OF EVIDECE: Therapeutic, IV.

Madrid and Santander, Spain

From private practice.

Received for publication July 12, 2018; accepted January 31, 2019.

Disclosure:The author has no financial interest to declare in relation to the content of this article.

Related digital media are available in the full-text version of the article on www.PRSJournal.com.

Francisco del Piñal, M.D., Dr. Med., Serrano 58-1B, E-28001 Madrid, Spain, drpinal@drpinal.com, pacopinal@gmail.com

Copyright © 2019 by the American Society of Plastic Surgeons