Thumb reconstruction--great toe transfer

Thumb reconstruction has a long and exciting history spanning more than 100 years. Reflecting on the evolution of techniques, the problems encountered and solved, and the advancement of technologies, one is struck by the versatility of surgeons in their varied approaches to the restoration of the thumb. Philosophical differences over the relative advantages and disadvantages of each operation have fueled debate over the choice of technique, but a unifying concept in reconstruction "to replace the lost tissue with like tissue" must be sought. The ideal reconstruction is one that replaces all of the lost structures, provides restoration of all function, and has no donor site morbidity. Homotransplantation of the thumb fits each of these criteria and may well be available some day. The experimental work of Furnas and others with limb transplantation is bringing us ever closer to realizing this goal. Even now, cadaver preparations of bone, joint, and tendon together with wrap-around flaps are being used clinically for thumb reconstruction. The initial reports are favorable, and these procedures portend exciting prospects for the future when immunological barriers can be selectively overcome. Some 10 years ago Dr. Littler, in discussing thumb reconstruction, wrote "Just as the neurovascular pedicle method of composite tissue transfer unshackled the older but limited procedures and made possible more accurate planning in substituting for the structural loss, so must the new freedom, afforded the transfer of composite tissue through microvascular surgery, not fail to utilize established structural and functional principles. Nor must the urge to use the free transfer method lure the surgeon from a safer, more predictable procedure." In the decade since Dr. Littler expressed these sentiments, a great deal of progress has been made in microsurgery, and we feel that there is ample evidence in our clinical experience as well as that of the literature to allow us to state with confidence that great toe to thumb transfer is a safe, reliable, and efficient means of thumb reconstruction that offers significant advantages over other techniques and few disadvantages. Anatomically, the great toe is nearly identical to the thumb and provides a transplant with tendon, bone, joint, and innervated skin elements that, in many instances, restores the attributes of the lost thumb in a superior fashion compared with other procedures. Our series now consists of 80 great toe transplants and the results continue to be gratifying. In short, great toes make great thumbs.