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Toe-to-Hand Transplantation after Failed Osteogenesis Distraction: A “Peg-in-Cup” Osteosynthesis

de Jesus, Ramon A. M.D.; Ferrari, Jonathan P. B.S.; Hemphill, Amani F. M.D.; Brooks, Darrell M.D.

Author Information
Plastic and Reconstructive Surgery: January 2009 - Volume 123 - Issue 1 - p 39e-40e
doi: 10.1097/PRS.0b013e31819056a3
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Psychosocial dysfunction secondary to inadequately treated congenital hand anomalies1 can have a dramatic presentation in preadolescence. Furthermore, these patients may desire cosmetic correction to reduce insecurities and raise self-confidence in their juvenile years. Factors complicating surgery may include a patient's psychological instability, the distorted anatomy from previous operations, and a risk of reduced function at the cost of cosmesis. The following case illustrates these points.

An 11-year-old girl presented with acrosyndactyly of the middle, index, and ring fingers of the right hand, secondary to amniotic band syndrome. At 18 months of age, she underwent separation of the involved digits, resulting in the loss of the middle finger at the level of the proximal interphalangeal joint. At the age of 4, hastened distraction osteogenesis resulted in a tapered bony segment of the middle proximal phalanx. The patient came to our care at the age of 11 after reports of glove hiding of her dominant, malformed hand and increased concerns of depression and social withdrawal. After thorough psychological testing and discussion regarding changes in foot appearance, digital arcade restoration via toe-to-hand transplantation was considered because of the potential psychosocial benefits.

Prior osteogenesis distraction had left the middle proximal phalanx of the affected hand elongated and tapered, complicating bony fixation. Due to the narrow diameter of the medullary canal of the distracted segment, prosthetic joint replacement was not considered. Plate fixation was unfavorable because of the step-off created by the different bone diameters. Bone shortening to facilitate plate fixation would have left an unacceptable final digit length. Lastly, one Kirschner wire might have passed through both bone segments, but this would not have prevented rotational forces from disrupting the union or allowed early range of motion. Consequently, the “peg-in-cup” osteosynthesis was devised to efficiently use the existing anatomy and minimize soft-tissue disruption, while maximizing bone-to-bone contact.

To create the peg-in-cup, the distal portion of the proximal phalanx was denuded of soft tissue and periosteum for 1 cm, resected transversely with a sagittal saw, and rounded with a rongeur to provide the peg. Next, the joint surface of the proximal phalanx of the second toe was removed with a sagittal saw, and a 1-cm intramedullary tunnel was made using small pineapple burr to create the recipient cup. Opposition of the peg within the medullary canal of the proximal phalanx was secured, while a 28-guage cerclage wire stabilized the osteosynthesis from rotating in the longitudinal axis (Fig. 1).

Fig. 1.
Fig. 1.:
(Left) Posteroanterior and (right) lateral postoperative views of peg-in-cup osteosynthesis. A single 0.28 Kirschner wire is visible.

Because bony fixation was necessary at the level of the proximal interphalangeal joint on the patient's dominant hand, failure to accommodate the new transplant was a concern. Several authors have stated that replantation at this level—proximal to the insertion of the flexor digitorum superficialis—can be detrimental to overall hand function due to reduction in range of motion and grip strength.2,3 However, by achieving a stable osteosynthesis and precise joint orientation, the patient was able to incorporate her new digit successfully into the repertoire of daily hand activity. Moreover, the patient and mother reported decreased anxiety and betterment in the patient's mood shortly thereafter, corroborating postoperative reports4,5 of other children and their parents after toe-to-hand transfer.

Ramon A. de Jesus,

Jonathan P. Ferrari, B.S.

Amani F. Hemphill, M.D.

Darrell Brooks, M.D.

Department of Surgery

Union Memorial Hospital

Department of Plastic Surgery

Johns Hopkins

Baltimore, Md.


1. Eskandari MM, Oztuna V, Demirkan F. Late psychosocial effects of congenital hand anomaly. Hand Surg. 2004;9:257.
2. Thomas F, Kaplan D, Raskin KB. Indications and surgical techniques for digit replantation. Bull Hosp Jt Dis. 2001–2002;60:179.
3. Soucacos PN. Indications and selection for digital amputation and replantation. J Hand Surg (Br). 2001;26:572.
4. Bellew M, Kay SP. Psychological aspects of toe to hand transfer in children: Comparison of views of children and their parents. J Hand Surg (Br). 1999;24:712.
5. Kay SP, Wiberg M, Bellew M, Webb F. Toe to hand transfer in children: Part 2. Functional and psychological aspects. J Hand Surg (Br). 1996;21:735.

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