A Demonstration of Long-Term Outcomes in a Case of Toe to Thumb Transfer Following Traumatic Amputation

Abstract

The thumb is pivotal to many functions of the hand. Loss or absence of the thumb can be catastrophic to a patient's functioning. Different methods can be employed to surgically fashion a new thumb. This case report aims to demonstrate one patient's 34-year experience, reporting objective measures for a toe to thumb transfer, and documenting aesthetic outcomes. A semi-structured interview was conducted to gain insight into the patient's personal experiences. Validated assessment tools were used to assess range of movement and power, including Kapandji test, Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, Cochin Hand Function Scale, Qingfeng Hand Dynamometer, Self-Administered Foot Evaluation Questionnaire (SAFE-Q). A physical examination on the neothumb was performed, along with photography to document aesthetic outcome. A 55-year-old white British male injured his right thumb whilst on a placement year in a sugar refinery in the Netherlands. The thumb was traumatically amputated proximal to the metacarpophalangeal joint. The patient lived for a year without a thumb on his dominant hand, which had a huge effect on his functioning, with extensive input from physiotherapists to help increase his handgrip strength. He then underwent a transfer operation, with the removal of the second toe which was transferred to create a right neothumb. The patient has high physical functioning of his neothumb, however, he is still mildly limited due to pain 34 years post-operation. The objective assessment tools demonstrate a high functioning of the neothumb, with only mild deficits in the dexterity and the physical functioning of the right hand. He experiences mild pain and reduced function of the donor foot. Light touch was found to be absent on the right thumb, but present on the left. Two-point discrimination was 7 mm on the right thumb, and 0.5 mm on the left. In this case, we present a toe to thumb transfer that had very good outcomes after 34 years with few complications. This case demonstrates that great adaptation can occur over long periods of time, restoring near-normal function. Measures of functional outcomes were generally high, with main deficiencies in fine motor skills such as picking up a penny from a flat surface and undoing small buttons. Additionally, there can be good long term outcomes from toe to thumb transfer despite moderate impairment of function. There is hope that this can be used to encourage and reassure patients and surgeons alike that the neothumb is likely to give good outcomes both functionally and aesthetically for many years.