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Our series of toe transplantations demonstrates that the quality of sensory return is comparable to that obtained after simple digital nerve repair in the hand after transection, and is particularly good in children.3 The sensory return to the transplanted toe or pulp islands may be greater than that to the identical area on the opposite foot,3 undoubtedly owing to sensory potentiation that comes with repeated use once the toe is transplanted to the hand. Toe transplants are considered superior to finger or thumb reconstruction by osteoplastic techniques, not only because of the sensory pulp with its dorsal nail support and normal appearance, but also because of active flexion of the multiple joints in the transplanted toe. Unfortunately, the metatarsal joint is more an extension joint than a flexion joint in the foot, but once it is transplanted to the hand, any degree of flexion is an asset. The interphalangeal joints and distal joints of the toe tend to keep their normal, somewhat flexed position once they are transplanted to the hand. This can be reduced by immobilizing the transplanted toe joints in extension and performing secondary tenolysis to increase small-joint movement.
Microvascular tissue transplantation from the toe to the hand can be considered in almost any injury requiring reconstruction, if one adopts the philosophy of transplanting the defect from the hand to the foot. In certain situations, this defect transfer is less acceptable than in others. For example, great toe transplantation is not popular in the Orient, where zori-type sandals, which require a first web space, are worn.4 Although loss of the great toe does not produce a functional problem, a cosmetic defect is produced that is less acceptable to some women whose shoe styles often expose the toes. In contrast, loss of the second toe produces a minimal functional or cosmetic defect in the foot, The use of the two adjacent toes is limited to cases in which all five fingers are missing and the primary goal is to restore a three-digit hand, but the defect on the foot is considerable, producing marked narrowing of the foot or a noticeable soft-tissue and bony defect.
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5 Thumb reconstruction by great-toe transplantation can be considered in any instance as long as at least a third of the proximal portion of the metacarpal bone is present. This brings about a better functional and cosmetic result than a second-toe transplantation. The great toe with a part of the first metatarsal head can occasionally be used for splitting the dorsal half of the first metatarsal head obliquely, but leaving the weight-bearing surface intact.6 Gait analysis studies have shown that the weight-bearing distribution shifts away from the first metatarsal head, but without substantial gait problems.7
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