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EXTREME THUMB LOSSES: RECONSTRUCTIVE STRATEGIES.

BACKGROUND
Complex amputations of the thumb, historically, have been managed in 2 stages and often require additional soft tissue and tendon transfers for successful outcomes. This paper provides several novel strategies to address these problems in a single stage utilizing 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, while the remainder had a great toe (or of a part of it) was used for the reconstruction. Suture, advancement or tendon transfers were done in all to restore intrinsic muscle function. In nineteen cases the web needed to be resurfaced with free (eighteen) or local (one) 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. The patients rated their functional and cosmetic result with a Visual Analogue Scale (0-10) of 8.5 and 8.4 respectively CONCLUSIONS:: In proximal thumb amputations, the surgeon should not only pay attention to the obvious thumb loss, but also to the first web and the thenar muscles. Based on our experience, we recommend 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. Despite our positive experience, further studies are required to compare the outcomes of these results to those of more classic transfers.