We read with great interest the article entitled “Immediate Reconstruction of a Nonreplantable Thumb Amputation by Great Toe Transfer” by Ray et al.1 The authors describe immediate transfer of the great toe to the hand in six patients following thumb amputation. The authors claim that this immediate one-stage transfer reduces hospitalization and shortens time of disability.
We would like to congratulate the authors for these impressive results. The idea of immediate reconstruction to optimize economic and therapeutic advantages is highly appreciated.
The nomenclature for time categories in the literature has produced confusion with regard to overlapping terms. The following enumeration of different terminologies should underline the dilemma: emergency (within 24 hours),2,3 immediate (within 24 hours), acute (within 5 days), early (<72 hours or 1 to 7 days), subacute (1 to 6 weeks), delayed (within 3 months), late (8 to 30 days or >3 months), and chronic (>6 weeks).
In our opinion, the term immediate or “emergency flap” suggests a procedure comparable to a replantation, which is mandatory in the first hours after trauma at the end of primary débridement.4 To clarify the terminology, we would suggest the following classification according to practical application:
- Immediate: during primary surgery (<12 to 24 hours).
- Delayed: after stabilization of the patient (<7 days).
- Secondary: after secondary referral to plastic surgery (>7 days).
According to this classification, only two of six cases described in the article meet the definition for the term immediate. Therefore, the title might be misleading, implying toe transfer during primary surgery. In our experience, patient selection for free microvascular transplantation involves careful evaluation of the needs of the patient. Risks and benefits of a free great-toe transfer cannot be estimated by a traumatized patient.
Moreover, in cases where replantation is no longer possible, as in crush injuries and avulsions, the risk of secondary tissue necrosis and thrombosis caused by intima rupture of the artery is increased, which can result in loss of the transplanted toe without gaining a useful thumb.
In the authors' opinion, an advantage of immediate toe transfer would be the shorter period to full rehabilitation of the patient. For unskilled manual workers, a short time of rehabilitation is mandatory; otherwise, they might lose their jobs. Thus, a rehabilitation period of 110 days on average gives rise to the question of whether there are alternatives for thumb reconstruction with a definite, shorter rehabilitation time (e.g., coverage with a groin flap for great tissue loss, or a Foucher flap for minor defects and deepening of the first web space to achieve better grip strength).5
Reconstruction of the thumb can be performed safely when delayed, keeping in mind that the delay should be as short as possible. This delay enables the surgeon to consider the treatment plan and gives him or her the opportunity to assess each patient's posttraumatic function and specific reconstructive needs carefully. In our opinion, there is no need to perform a real immediate great toe-to-hand transfer.
Jörn Redeker, M.D.
Christine Radtke, M.D.
Alexander Handschin, M.D.
Peter M. Vogt, Ph.D.
Department of Plastic, Hand, and Reconstructive Surgery
Hannover Medical School
1. Ray EC, Sherman R, Stevanovic M. Immediate reconstruction of a nonreplantable thumb amputation by great toe transfer. Plast Reconstr Surg
2. Lister G, Scheker L. Emergency free flaps to the upper extremity. J Hand Surg (Am.)
3. Ninkovic M, Deetjen H, Ohler K, Anderl H. Emergency free tissue transfer for severe upper extremity injuries. J Hand Surg (Br.)
4. Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg
5. Heitmann C, Levin LS. Alternatives to thumb replantation. Plast Reconstr Surg
. 2002;110:1492–1503; quiz 1504–1505.
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