JBJS | Transfer of a Severely Damaged Digit to Reconstruct an Amputated Thumb*

The Journal of Bone & Joint Surgery, Volume 78, Issue 12

Articles | December 01, 1996

Transfer of a Severely Damaged Digit to Reconstruct an Amputated Thumb*

GUY FOUCHER, M.D.†, STRASBOURG; SORAYA ROSTANE, M.D.‡; MICHEL CHAMMAS, M.D.‡; DAVID SMITH, M.D.§; YVES ALLIEU, M.D.‡, MONTPELLIER, FRANCE

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Investigation performed at SOS Main Strasbourg, Strasbourg, and SOS Main Montpellier, Montpellier

The Journal of Bone & Joint Surgery. 1996; 78:1889-96

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Abstract

We retrospectively reviewed the results of reconstruction of a traumatically amputated thumb with use of an adjacent severely damaged digit in twenty-seven patients (twenty-five male and two female patients). The mean duration of follow-up was nine years (range, two to twenty-one years). The mean age at the time of the reconstruction was thirty-four years (range, thirteen to fifty-six years). Five patients had the reconstruction on the day of the injury and twenty-two, after a mean delay of five months (range, fifteen days to thirteen months). Segments of the index finger were used in twenty-two patients; of the long finger, in four patients; and of the ring finger, in one patient. There were four complications: necrosis of the dorsal skin in one patient, reflex sympathetic dystrophy in one patient, and contracture of the first web space in two patients.Discriminative sensibility was ten millimeters or less, according to the Weber test, in twenty-four thumbs. Cortical integration with reference to the recipient thumb, on stimulation of the pollicized segment, was good in ten patients. Eleven patients could achieve tip-to-tip contact between the thumb and the little finger and twenty-five patients, between the thumb and the most radial finger. The ability to perform activities of daily living was considered good for ten patients, fair for eleven, and poor for six. Only digits with a nail, either present on the transferred segment or as a result of a free vascularized nail transfer, were considered to have a good cosmetic result.Although these results are far from impressive, the reconstruction is a viable alternative for selected patients because it maintains the ability to grasp objects and to oppose the digits.

Figures in this Article

Introduction

Introduction | Materials and Methods | Results | Discussion | References

The reconstruction of an amputated thumb remains a major challenge, as evidenced by the different reconstructive techniques that have been described. These procedures include a simple deepening of the first web space⁴⁷, transfer of a toe with use of microvascular technique^3,13,11,38, transposition of local structures or digits^{4,10,14,17-19,23,31,32,34,40}, and lengthening of the remaining thumb^12,35,36. The goal of all of these procedures is to provide a painless thumb with good stability, sensibility, and mobility to oppose the adjacent fingers. Despite the increased popularity of toe-to-hand transfer and the lack of adequate long-term studies^{6,15,28,44,46}, pollicization of a damaged digital segment remains a viable option when the thenar muscles and the trapeziometacarpal joint have been destroyed^31,33. We reviewed the results of pollicization of a severely damaged digit to reconstruct a traumatically amputated thumb.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†SOS Main Strasbourg, 4, Boulevard du President-Edwards, Strasbourg 67000, France.

‡SOS Main Montpellier, Hopital Lapeyronie, 555 Route de Ganges, Montpellier 34059, France.

§Section of Plastic Surgery, University of Michigan Hospitals, 1500 East Medical Center Drive, Ann Arbor, Michigan 48109-0314.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†SOS Main Strasbourg, 4, Boulevard du President-Edwards, Strasbourg 67000, France.

‡SOS Main Montpellier, Hopital Lapeyronie, 555 Route de Ganges, Montpellier 34059, France.

§Section of Plastic Surgery, University of Michigan Hospitals, 1500 East Medical Center Drive, Ann Arbor, Michigan 48109-0314.

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TABLE I PREOPERATIVE AND POSTOPERATIVE CLINICAL DATA FOR THETWENTY-SEVEN PATIENTS

*3 = good, 2 = fair, and 1 = poor.†2 = total, 1 = partial, and 0= none.

		No. of Digits Involved	Finger Transferred	Level of Amp. (Group⁷)	Vascular Structures Used				Kapandji Score²⁵	Cortical Integration†		Durat. of Follow-up
Case	Age	Artery	Vein	Nerve	Sensibility*	Function
	(Yrs.)											(Yrs.)
1	34	3	Index	2	Palmar(2)	Dorsal pedicle	Neurotization	3	8	2	Good	8
2	17	2	Index	2	Palmar(2)	Dorsal sutured vein	Neurotization	3	8	2	Good	8
3	38	3	Long	1	Dorsal	Dorsal vein sutured	Neurotization	3	7	2	Good	6
4	44	2	Index	1	Palmar(1)	Dorsal pedicle	Intact	3	8	2	Good	13
5	22	3	Index	1	Palmar(2)	Dorsal pedicle	Intact	3	8	2	Good	2
6	14	2	Index	2	Palmar(2)	Dorsal pedicle	Intact	3	8	2	Good	15
7	38	2	Index	2	Palmar(2)	Dorsal pedicle	Intact	2	6	2	Good	12
8	50	5	Index	3	Palmar(2)	Dorsal pedicle	Intact	3	6	2	Good	17
9	19	2	Index	2	Palmar(2)	Dorsal pedicle	Intact	3	7	2	Good	17
10	13	2	Index	2	Palmar(2)	Dorsal pedicle	Intact	3	7	2	Good	13
11	47	2	Index	3	Palmar(1)	Dorsal pedicle	Intact	2	5	1	Fair	7
12	29	4	Index	2	Dorsal	Dorsal pedicle	Intact	2	6	1	Fair	2
13	46	4	Long	3	Palmar(1)	Dorsal vein sutured	Intact	2	5	1	Fair	2
14	27	4	Index	2	Palmar(2)	Dorsal vein sutured	Intact	2	4	1	Fair	4
15	56	2	Index	2	Palmar(1)	Dorsal pedicle	Intact	2	5	1	Fair	9
16	41	5	Index	2	Palmar(1)	Dorsal pedicle	Intact	2	5	1	Fair	14
17	33	3	Long	2	Palmar(1)	Dorsal vein sutured	Intact	2	5	1	Fair	5
18	28	5	Index	2	Palmar(1)	Dorsal pedicle	Intact	2	4	1	Fair	12
19	50	2	Index	2	Palmar(2)	Dorsal pedicle	Intact	2	5	1	Fair	21
20	45	2	Index	2	Dorsal	Dorsal pedicle	Intact	2	4	1	Fair	10
21	25	3	Long	2	Palmar(2)	Dorsal vein sutured	Intact	2	5	1	Fair	12
22	35	5	Index	2	Palmar(2)	Dorsal pedicle	Intact	2	5	0	Poor	6
23	29	3	Ring	2	Palmar(2)	Dorsal pedicle	Intact	2	4	0	Poor	9
24	23	3	Index	2	Palmar(2)	Dorsal pedicle	Intact	2	4	0	Poor	10
25	56	5	Index	2	Palmar(2)	Dorsal pedicle	Intact	1	2	0	Poor	5
26	20	5	Index	2	Palmar(1)	Dorsal pedicle	Intact	1	4	0	Poor	5
27	37	2	Index	2	Palmar(2)	Dorsal pedicle	Intact	1	2	0	Poor	8

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TABLE I PREOPERATIVE AND POSTOPERATIVE CLINICAL DATA FOR THETWENTY-SEVEN PATIENTS

*3 = good, 2 = fair, and 1 = poor.†2 = total, 1 = partial, and 0= none.

		No. of Digits Involved	Finger Transferred	Level of Amp. (Group⁷)	Vascular Structures Used				Kapandji Score²⁵	Cortical Integration†		Durat. of Follow-up
Case	Age	Artery	Vein	Nerve	Sensibility*	Function
	(Yrs.)											(Yrs.)
1	34	3	Index	2	Palmar(2)	Dorsal pedicle	Neurotization	3	8	2	Good	8
2	17	2	Index	2	Palmar(2)	Dorsal sutured vein	Neurotization	3	8	2	Good	8
3	38	3	Long	1	Dorsal	Dorsal vein sutured	Neurotization	3	7	2	Good	6
4	44	2	Index	1	Palmar(1)	Dorsal pedicle	Intact	3	8	2	Good	13
5	22	3	Index	1	Palmar(2)	Dorsal pedicle	Intact	3	8	2	Good	2
6	14	2	Index	2	Palmar(2)	Dorsal pedicle	Intact	3	8	2	Good	15
7	38	2	Index	2	Palmar(2)	Dorsal pedicle	Intact	2	6	2	Good	12
8	50	5	Index	3	Palmar(2)	Dorsal pedicle	Intact	3	6	2	Good	17
9	19	2	Index	2	Palmar(2)	Dorsal pedicle	Intact	3	7	2	Good	17
10	13	2	Index	2	Palmar(2)	Dorsal pedicle	Intact	3	7	2	Good	13
11	47	2	Index	3	Palmar(1)	Dorsal pedicle	Intact	2	5	1	Fair	7
12	29	4	Index	2	Dorsal	Dorsal pedicle	Intact	2	6	1	Fair	2
13	46	4	Long	3	Palmar(1)	Dorsal vein sutured	Intact	2	5	1	Fair	2
14	27	4	Index	2	Palmar(2)	Dorsal vein sutured	Intact	2	4	1	Fair	4
15	56	2	Index	2	Palmar(1)	Dorsal pedicle	Intact	2	5	1	Fair	9
16	41	5	Index	2	Palmar(1)	Dorsal pedicle	Intact	2	5	1	Fair	14
17	33	3	Long	2	Palmar(1)	Dorsal vein sutured	Intact	2	5	1	Fair	5
18	28	5	Index	2	Palmar(1)	Dorsal pedicle	Intact	2	4	1	Fair	12
19	50	2	Index	2	Palmar(2)	Dorsal pedicle	Intact	2	5	1	Fair	21
20	45	2	Index	2	Dorsal	Dorsal pedicle	Intact	2	4	1	Fair	10
21	25	3	Long	2	Palmar(2)	Dorsal vein sutured	Intact	2	5	1	Fair	12
22	35	5	Index	2	Palmar(2)	Dorsal pedicle	Intact	2	5	0	Poor	6
23	29	3	Ring	2	Palmar(2)	Dorsal pedicle	Intact	2	4	0	Poor	9
24	23	3	Index	2	Palmar(2)	Dorsal pedicle	Intact	2	4	0	Poor	10
25	56	5	Index	2	Palmar(2)	Dorsal pedicle	Intact	1	2	0	Poor	5
26	20	5	Index	2	Palmar(1)	Dorsal pedicle	Intact	1	4	0	Poor	5
27	37	2	Index	2	Palmar(2)	Dorsal pedicle	Intact	1	2	0	Poor	8

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Fig. 1 Drawing showing the palmar incision used to perform the pollicization of the segment of the index finger.

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Figs. 2-A through D: Photographs showing the appearance and the function of the hand before and after the operation. Fig. 2-A: The preoperative appearance of the hand as seen from the palmar aspect. The palmar incision for dissection of the segment from the middle finger is outlined.

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Fig. 2-B: Extension.

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Fig. 2-C: Flexion.

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Fig. 2-D: Opposition.

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Fig. 3 Diagram showing the Kapandji²⁵ scoring system for opposition of the thumb.

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

Reconstruction of a traumatically amputated thumb with use of an adjacent damaged digit was performed in twenty-seven patients between 1971 and 1991 at two institutions (SOS Main Strasbourg [eighteen patients] and SOS Main Montpellier [nine patients]) (Table I). There were twenty-five male and two female patients. The mean age at the time of the reconstruction was thirty-four years (range, thirteen to fifty-six years). The dominant hand was injured in thirteen patients. At the time of the injury, eighteen patients were employed as manual laborers, five worked in white-collar positions, and four were unemployed. Fifteen hands were injured by a power saw; five, in a spindle-molding machine; three, in a press; and four, in a blast injury. The thumb was amputated at the level of the proximal phalanx in three patients, distal to or at the interphalangeal joint in five, and at the metacarpal in nineteen.

The amputation of the thumb was classified with use of the criteria proposed by Campbell Reid and McGrouther⁷. According to this classification, group 1 comprises thumbs that have been amputated distal to the metacarpophalangeal joint, with an adequate stump; group 2, those that have been amputated distal to or through the metacarpophalangeal joint, with an inadequate stump; group 3, those that have been amputated through the metacarpal, with preservation of some thenar muscles; and group 4, those that have been amputated at or near the carpometacarpal joint, with loss of all of the thenar muscles. On the basis of this classification, three thumbs were in group 3, twenty-one were in group 2, and three were in group 1.

One adjacent digit or more were injured in all twenty-seven patients. In addition to the thumb, one ray was injured in eleven patients; two, in seven; three, in three; and four, in six. Five patients had the reconstruction on the day of the injury and the remaining twenty-two, after a mean delay of five months (range, fifteen days to thirteen months). Segments of the index finger were pollicized in twenty-two patients; of the long finger, in four patients; and of the ring finger, in one patient.

Operative Technique

The classic technique of island transfer^4,18,32 was used with several modifications. A palmar approach was used to transfer the segment of the index finger (Fig. 1) without the long dorsal incision usually performed for resection of the second ray. With a pure palmar approach, a conspicuous dorsal scar is avoided, and the anterior approach facilitates the oblique bone cut of the second metacarpal (Fig. 2-A). A curved incision on the recipient thumb is used to provide a flap to cover the ulnar aspect of the stump. The palmar digital arteries of the first and second web spaces, when intact, are dissected after section of the radial digital artery of the long finger; sufficient length is necessary for easy transposition and to avoid narrowing of the first web space. An endoneurolysis of the nerves of the second web space is necessary to avoid any traction on the bundles after the transfer, and the dorsal vein is easily mobilized after the proximal osteotomy of the second metacarpal.

When a digit other than the index finger is used, the technique is identical; however, it is not possible to preserve the continuity of a dorsal vein. The palmar bundle, dissected en bloc with surrounding fat, contains some veins, but in the event of earlier trauma to the palmar tissues we dissect a dorsal vein on the donor finger and suture it to the cephalic vein, through a short transverse dorsal incision, after tunneling beneath the intact dorsal skin. This method was used in four patients. An atypical technique was sometimes used because of previous trauma to the hand. Two palmar interdigital arteries were available in fourteen patients, and the transfer was based on only one such artery in ten. The palmar inter-osseous artery was used in two other patients, and the first dorsal metacarpal artery was used in one patient, in whom the two palmar nerves were intact. Microsurgical anastomosis of the vein was performed in two patients, and a previous injury of the collateral nerve necessitated repair in three patients.

A nail was present on the pollicized segment from five patients, three of whom had been managed acutely. Three patients had a free vascularized transfer of a toenail: one of them had transfer of a nail flap from the second toe because of necrosis of the dorsal skin of the pollicized digit, and two had transfer of the nail from the great toe for cosmetic purposes. An end-to-side arterial anastomosis and an end-to-end venous suture was performed through a short transverse incision at the level of the anatomical snuff box, after undermining of the dorsal skin.

The bone was stabilized with two Kirschner wires placed in a crossed position in twenty patients and in the intramedullary canal in one patient. Additional procedures, such as resection of the proximal segment of the second ray, were performed in all patients who had pollicization of the index finger. Twelve patients had a revision of the web space, which had been anticipated preoperatively for ten of them. A remote flap was used in two patients; a local flap, in nine patients; and a skin graft, in one patient.

The evaluation was performed by an independent observer (S. R.) at a mean of nine years (range, two to twenty-one years) postoperatively. The assessment took into account function (mobility, sensibility, and strength), quality of life (pain, intolerance to cold, ability to perform activities of daily living, and return to work), and cosmetic appearance. We tried to establish a global score. Mobility of the first ray was measured with a goniometer when there was an intact metacarpophalangeal joint. Opposition of the thumb was assessed with the scoring system described by Kapandji²⁵. With this system, the patient brings the tip of the thumb into contact with the tip of each finger and then down the fifth ray (Fig. 3). The maximum score, for reaching a joint proximal to the fifth digit, is 10 points. The adequacy of the first web space was assessed by having the patient grasp cylinders of different diameters and comparing the findings with those for the normal, contralateral side, or, in patients who had bilateral injury, by measuring the angle between the first and second metacarpals on radiographs.

Sensibility was measured with use of the Weber test. Cortical integration was evaluated by asking the patient to identify the digit being stimulated; some patients identified the thumb when the tip of the pollicized digit was touched whereas others continued to identify it as the donor ray. Grasp and pinch strength were assessed with the Jamar dynamometer (with use of the pinch meter of the device); a coefficient of correction for dominance (10/9) was used, according to the method reported by Jarit^24,37. Patients graded residual pain secondary to a neuroma or intolerance to cold relative to the degree of interference with their activities of daily living.

Activities of daily living, such as dressing, writing, and eating, were assessed by interviewing the patient and observing the use or lack of use of the reconstructed thumb. Changes in hand dominance, time missed from work, and return to work status were documented. The appearance of the thumb was assessed with the patient taking into account any trophic changes, the presence or absence of a nail, and the diameter of the thumb.

We found the standard assessment of function of the thumb to be inadequate for evaluation of these severely injured hands. We therefore devised a classification system that reflects more accurately the functional and cosmetic results. According to this system, a good result is characterized by an ability to perform activities requiring pinch; a Kapandji²⁵ score of 6, 7, or 8 points; good sensibility; total cortical reorientation; an ability to grasp cylinders at least nine centimeters in diameter; no change in hand dominance; return to the job held before the injury; and no symptoms referable to the hand. A fair result is characterized by an ability to perform activities with use of pinch and grip, a Kapandji²⁵ score of 4 or 5 points, fair sensibility, incomplete cortical reorientation, an ability to grasp cylinders less than nine centimeters in diameter, an inability to perform the job held before the injury, moderate symptoms, and moderate interference with daily activities. A poor result is characterized by an inability to perform activities requiring pinch or opposition, poor sensibility, and a major disturbance of function.

Results

Introduction | Materials and Methods | Results | Discussion | References

Complications

There were four complications. One patient had necrosis of the dorsal skin of the pollicized digit, which was subsequently covered with a free flap from the second toe, including the nail; one had reflex sympathetic dystrophy with stiffness and limited function of the thumb; and two had contracture of the web space, which made it difficult to grasp large objects. The latter three patients were considered to have a poor result.

Motion

Motion, as assessed with the global score of Kapandji²⁵, was good in eleven patients. These patients had a normal carpometacarpal joint, and seven also had an intact metacarpophalangeal joint. Five of the seven had an intact interphalangeal joint and had better mobility; however, as seen in four patients, absence of the metacarpophalangeal and interphalangeal joints did not preclude good function. All eleven patients had revision of the first web space. Fourteen patients had fair motion, with a useful distal pinch between the transposed digit and the long or ring finger. None of these patients had a metacarpophalangeal joint, but all had a functional carpometacarpal joint. The two patients who had poor motion had a contracture of the first web space.

Discriminative Sensibility

Sensibility was assessed with the Weber test. Nine patients had two-point discrimination of less than six millimeters; this group included four of the five patients who had had acute pollicization and the three who had had suture of the nerve at the recipient site. Fifteen patients had between six and ten millimeters of two-point discrimination. The three remaining patients had simple protective sensibility without two-point discrimination; two had had postoperative complications and the third was fifty-six years old. All patients had intolerance to cold, but it was associated with decreased function in only four.

Cortical Integration

Cortical integration with localization to the thumb on touch or pinprick of the transferred digit was good in ten patients; this group included the three patients who had had suture of the nerve and patients who had good two-point discrimination. The remaining seventeen patients had only partial cortical reorientation, with occasional reference to the donor finger on painful stimulation.

Strength Assessment

Nine of the patients who had an injury of one other ray in addition to the thumb had a mean grasp that was 78 per cent of that on the contralateral side. Ten of the patients who had an injury of the long finger had a mean pinch that was 75 per cent of that on the contralateral side. Eleven of the patients who had an injury of two rays or more in addition to the thumb had a mean pinch that was 50 per cent of that on the contralateral side.

Function

Function was assessed in terms of activities of daily living (Fig. 2-B, 2-C, and 2-D). The ability to pinch between the thumb and the fingers depended on sensibility, cortical integration, mobility, and the length of the thumb. Tip-to-tip contact was able to be achieved between the thumb and the little finger by eleven patients and between the thumb and the most radial finger by twenty-five. Ten patients had good function; eleven, fair; and six, poor. The group that had a fair result included three patients who had intolerance to cold that was associated with decreased function. The group that had a poor result included three patients who had had complications and three (all of whom were receiving disability compensation) who avoided the use of the thumb in manual activities. Of the latter three patients, one had a slightly narrow web space and two had no obvious anatomical problems. Eighteen patients, who had had a delayed reconstruction, thought that function had been improved by the operation, but activities such as buttoning and unbuttoning the clothes and picking up a coin remained difficult.

Of the twenty-seven patients, fifteen (eleven of whom had been receiving disability compensation) returned to their previous job, at a mean of five months (range, two to twenty-four months) after the operation; seven changed jobs (four, before the pollicization procedure); and four (all of whom were receiving disability compensation) remained unemployed. Nine of the thirteen patients who had had involvement of the dominant hand maintained the original dominance.

Cosmetic Appearance

Only the five patients who had a nail on the pollicized digit (three of whom had been managed acutely) and the three who had had reconstruction of the nail by microvascular transfer rated the cosmetic result as good. Seven patients expressed dissatisfaction with the cosmetic result only in response to a specific question.

Factors Related to Outcome

None of the parameters that were assessed were significant, but some seemed to influence the outcome positively. These factors included the age of the patient, the dominance of the injured hand, the number of fingers amputated, the level of the amputation, the timing of the operation, and the suppleness of the first web space.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

The earliest known reports of procedures similar to the reconstruction performed in the current study were by Guermonprez¹⁹ (1887), Dunlop⁹ (1923), and Bunnell⁴ (1952). Littler^31,32 standardized the technique and stressed the possibility of transferring a damaged finger with only one vascular pedicle. Søiland⁴⁵ introduced the term on-the-top plasty, but no thumb was included in his report. Most reports have included small numbers of patients^{2,5,15,28,30,44,46,49}, with the majority being case reports^{8,9,16,21,29,39,41,42,48}. Acute pollicization has been mentioned even less frequently in the literature^{15,20,26,27,43}. Most authors have reported good results without detailed data, except for Langlais et al.³⁰, who reported generally poor results.

The current study indicates that there are only a few prerequisites to ensure the success of this technique; some are related to the recipient thumb and others, to the donor finger. The carpometacarpal joint and the thenar muscles must be preserved, and the first web space must be either intact or capable of being reconstructed. The segment that is being considered for pollicization must be long enough to allow opposition with the remaining fingers after the transfer. The digit that is to be transposed must have good distal sensibility without a painful neuroma. At least one artery must be intact, and the neighboring fingers must retain at least one feeding artery after the transfer. Other factors that must be assessed include the age and psychological status of the patient, associated vascular disease, work and leisure activities, concerns and expectations relative to the cosmetic appearance, and the time that has elapsed since the injury as a long delay compromises the functional result.

We do not hesitate to perform the reconstruction on the day of the injury because the technique is simpler than a delayed procedure, in which palmar scarring often makes dissection of the pedicles technically difficult and sometimes impossible. However, contamination and severe crush injury with a decreased vascular supply to the palmar skin are definite contraindications to an acute repair. In such situations, we preserve the donor finger in its anatomical position. The finger to be transferred must have at least one intact neurovascular pedicle^22,32. Some authors²⁷ always make an arteriogram; we agree that this is useful when the vessels may have been compromised, but we performed such a study for only one patient.

It is worthwhile to emphasize some technical aspects of the procedure. When a segment of the index finger is used for pollicization, the anterior approach makes it unnecessary to perform an additional dorsal incision to resect the proximal part of the second ray; this approach renders the procedure less demanding and helps to avoid a conspicuous dorsal scar. Pollicization of other digits can be facilitated by anastomosis of the dorsal vein through a short transverse incision and translocation of the adjacent finger. The first web space may be compromised by contracture of a scar and a short vascular pedicle. The presence of scar tissue or insufficient skin necessitates additional flap coverage either before or at the time of the pollicization. Distal flaps are preferred because they help to avoid additional local scar formation and they add supple tissue to the area.

Pollicization of a segment of an injured finger has several advantages. It provides one-stage lengthening, a predictable length, and satisfactory long-term stability because of the presence of vascularized bone. The sensibility of the fragment remains the same as before the transfer; this is an advantage compared with toe transfer, the results of which have sometimes been disappointing. The disadvantages of pollicization include the inconsistent cortical reorientation, the technically demanding nature of the procedure, and the fact that it does not usually provide additional mobility. A major problem for a patient who has had amputation of several fingers is that the technique does not add tissues but simply shifts them. Thus, there is an advantage to the use of toe transfer in younger patients. Another disadvantage is the bulky appearance of the thumb, especially with incorporation of the metacarpophalangeal joint. Absence of the nail is frequent after all distal amputations, and this leads to a poor cosmetic result; however, this can sometimes be resolved by performing a nail transfer. Despite all of the problems and limitations, we found that, in our carefully selected series of twenty-seven patients, pollicization of severely injured fingers provided satisfactory functional results.

References

Introduction | Materials and Methods | Results | Discussion | References

Allende, B.-T., and |and |Wilson, J.-N.: Chirurgie reconstructive du pouce. Possibilités offertes par l'utilisation de doigts voisins blessés. A propos de 4 observations. Rev. chir. orthop.,54: 715-724, 1968.54715 1968 [PubMed]

Brunelli, G. A., and |and |Brunelli, G. R.: Reconstruction of traumatic absence of the thumb in the adult by pollicization. Hand Clin.,8: 41-55, 1992.841 1992 [PubMed]

Buncke, H. J., Jr.; McLean, D. H.; George, P. T.; Creech, B. J.; Charter, N. L.; and |and |Commons, G. W.: Thumb replacement: great toe-transplantation by microvascular anastomosis. British J. Plast. Surg.,26: 194-201, 1973.26194 1973 [CrossRef]

Bunnell, S.: Digit transfer by neurovascular pedicle. J. Bone and Joint Surg.,34-A: 772-774, Oct. 1952.34-A772 1952

Campbell Reid, D. A.: Reconstruction of the thumb. J. Bone and Joint Surg.,42-B(3): 444-465, 1960.42-B(3)444 1960

Campbell Reid, D. A.: Pollicization of stumps. In Reconstruction of the Thumb, pp. 128-141. Edited by A. Landi, S. De Luca, and G. De Santis. New York, Van Nostrand Reinhold, 1989.

Campbell Reid, D. A., and McGrouther, D. A. [editors]: Pollicization. In Surgery of the Thumb, pp. 92-105. Boston, Butterworths, 1986.

Chase, R. A.: An alternative to pollicization in subtotal thumb reconstruction. Plast. and Reconstr. Surg.,44: 421-430, 1969.44421 1969 [CrossRef]

Dunlop, J.: The use of the index finger for the thumb: some interesting points in hand surgery. J. Bone and Joint Surg.,5: 99-103, Jan. 1923.599 1923

Foucher, G.: La reconstruction après amputation traumatique du pouce. Livre des Conférences du GEM, pp. 65-76. Paris, Expansion Scientifique Française, 1993.

Foucher, G., and Van Der Kar, T.: Twisted two toes technique in thumb reconstruction. In Reconstruction of the Thumb, pp. 275-279. Edited by A. Landi, S. De Luca, and G. De Santis. New York, Van Nostrand Reinhold, 1989.

Foucher, G.; Hultgren, T.; Merle, M.; and |and |Braun, J. M.: L'allongement digital selon Matev. A propos de vingt cas. Ann. chir. main,7: 210-216, 1988.7210 1988 [PubMed][CrossRef]

Foucher, G.; Merle, M.; Maneaud, M.; and |and |Michon, J.: Microsurgical free partial toe transfer in hand reconstruction: a report of 12 cases. Plast. and Reconstr. Surg.,65: 616-627, 1980.65616 1980 [CrossRef]

Foucher, G.; Van Genechten, F.; Merle, N.; and |and |Michon, J.: Single stage thumb reconstruction by a composite forearm island flap. J. Hand Surg.,9-B: 245-248, 1984.9-B245 1984

Foucher, G.; Hoang, P. H.; Dury, M.; Merle, M.; and |and |Braun, F. M.: La pollicisation en urgence et en secondaire de segments digitaux mutilés. A propos de seize cas. Ann. chir. plast. esthét.,33: 54-57, 1988.3354 1988 [PubMed]

Frackelton, W. H., and |and |Teasley, J. L.: Neurovascular island pedicle—extension in usage. J. Bone and Joint Surg.,44-A: 1069-1072, Sept. 1962.44-A1069 1962

Gillies, H. D., and Millard, D. R.: The Principles and Art of Plastic Surgery. Boston, Little, Brown, 1957.

Gosset, J.: La pollicisation de l'index. (Technique chirurgicale.). J. chir.,65: 403-411, 1949.65403 1949

Guermonprez, J.: Notes sur quelques résections et restaurations du pouce. Paris, R. Asselin, 1887.

Harkins, P. D., and |and |Raffety, J. E.: Digital transposition in the injured hand. J. Bone and Joint Surg.,54-A: 1064-1069, July 1972.54-A1064 1972

Haussmann, P., and |and |Kohnlein, H. E.: Rekonstruktion des Daumenstrahles durch "on-top plasty.". Handchirurgie,8: 145-147, 1976.8145 1976

Herndon, J. H.; Littler, J. W.; Watson, F. M.; and |and |Eaton, R. G.: Traumatic amputation of the thumb and three fingers: treatment by digital pollicization. A case report. J. Bone and Joint Surg.,57-A: 708-709, July 1975.57-A708 1975

Hilgenfeldt, O.: Operativer Daumenersatz. Stuttgart, Ferdinand Enke, 1950.

Jarit, P.: Dominant-hand to non-dominant hand grip strength ratios of college baseball players. J. Hand Ther.,123-126, 1995.123 1995

Kapandji, A. L.: Clinical evaluation of the thumb's opposition. J. Hand Ther.,3: 102-106, 1992.3102 1992

Kaplan, I.: Primary pollicization of injured index finger following crush injury. Plast. and Reconstr. Surg.,37: 531-535, 1966.37531 1966 [CrossRef]

Keiter, J. E.: Immediate pollicization of an amputated index finger. J. Hand Surg.,5: 584-585, 1980.5584 1980

Kelleher, J. C.; Sullivan, J. G.; Baibak, G. J.; and |and |Dean, R. K.: "On-top plasty" for amputated fingers. Plast. and Reconstr. Surg.,42: 242-248, 1968.42242 1968 [CrossRef]

Kessler, I.: Cross transposition of short amputation stumps for reconstruction of the thumb. J. Hand Surg.,10-B: 76-78, 1985.10-B76 1985

Langlais, J.; Tubiana, R.; Gosset, J.; and Campbell Reid, D. A.: 12 cas de pollicisations atypiques. Monographies du GEM, pp. 158-163. Paris, Expansion Scientifique Française, 1984.

Littler, J. W.: Subtotal reconstruction of the thumb. Plast. and Reconstr. Surg.,10: 215-226, 1952.10215 1952 [CrossRef]

Littler, J. W.: The neurovascular pedicle method of digital transposition for reconstruction of the thumb. Plast. and Reconstr. Surg.,12: 303-319, 1953.12303 1953 [CrossRef]

Littler, J. W.: On making a thumb: one hundred years of surgical effort. J. Hand Surg.,1: 35-51, 1976.135 1976

McGregor, I. A., and |and |Simonetta, C.: Reconstruction of the thumb by composite bone-skin flap. British J. Plast. Surg.,17: 37-48, 1964.1737 1964 [CrossRef]

Matev, I. B.: Thumb reconstruction in children through metacarpal lengthening. Plast. and Reconstr. Surg.,64: 665-669, 1979.64665 1979 [CrossRef]

Matev, I. B.: Thumb reconstruction through metacarpal bone lengthening. J. Hand Surg.,5: 482-487, 1980.5482 1980

Mathiowetz, V.; Kashman, N.; Volland, G.; Weber, K.; Dowe, M.; and |and |Rogers, S.: Grip and pinch strength: normative data for adults. Arch. Phys. Med. and Rehab.,66: 69-74, 1985.6669 1985

Morrison, W. A.; O'Brien, B. McC.; and |and |MacLeod, A. M.: Thumb reconstruction with a free neurovascular wrap-around flap from the big toe. J. Hand Surg.,5: 575-583, 1980.5575 1980

Moss, A. L., and |and |Waterhouse, N.: One stage thumb reconstruction using a previously injured little finger from the contralateral hand. J. Hand Surg.,10-B: 73-75, 1985.10-B73 1985

Nicoladoni, C.: Daumenplastik und organischer Ersatz der Fingerspitze. (Anticheiroplastik und Daktyloplastik.). Arch. klin. Chir.,61: 606-614, 1900.61606 1900

Rico Aguado, A.; Najera Tesseiner, A.; Rodriguez, E.; and |and |Moreno T.: Indikationsstellung und Technik bei der Rekonstruktion schwer verstummelter Hande. Handchirurgie,15: 49-54, 1983.1549 1983

Roullet, J.; Noirclerc, J. A.; and |and |Landreau, F. R.: De la pollicisation. Soc. Chir. Lyon,67: 114-121, 1971.67114 1971

Sallis, J. G.: Primary pollicisation of an injured middle finger. J. Bone and Joint Surg.,45-B(3): 503-505, 1963.45-B(3)503 1963

Schoofs, M., and |and |Leps, P.: Intérêt de la pollicisation dans la reconstruction du pouce traumatique de l'adulte. Réflexions à propos de quinze cas. Ann. chir. main,11: 19-26, 1992.1119 1992

Søiland, H.: Lengthening a finger with the "on the top" method. Acta Chir. Scandinavica,122: 184-186, 1961.122184 1961

Stern, P. J., and |and |Lister, G. D.: Pollicization after traumatic amputation of the thumb. Clin. Orthop.,155: 85-94, 1981.15585 1981 [PubMed]

Tubiana, R., and |and |Roux, J.-P.: Phalangization of the first and fifth metacarpals. Indications, operative technique, and results. J. Bone and Joint Surg.,56-A: 447-457, April 1974.56-A447 1974

Verral, P.J.: Three cases of reconstruction of the thumb. Some interesting points in hand surgery. J. Bone and Joint Surg.,5: 99-103, 1923.599 1923

Ward, J. W.; Pensler, J. M.; and |and |Parry, S. W.: Pollicization for thumb reconstruction in severe pediatric hand burns. Plast. and Reconstr. Surg.,76: 927-932, 1985.76927 1985 [CrossRef]

Zachary, R. B., and |and |Holmes, W.: Primary suture of nerves. Surg. Gynec. and Obstet.,82: 632-651, 1946.82632 1946

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Fig. 1 Drawing showing the palmar incision used to perform the pollicization of the segment of the index finger.

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Fig. 2-B: Extension.

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Fig. 2-C: Flexion.

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Fig. 2-D: Opposition.

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Fig. 3 Diagram showing the Kapandji²⁵ scoring system for opposition of the thumb.

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TABLE I PREOPERATIVE AND POSTOPERATIVE CLINICAL DATA FOR THETWENTY-SEVEN PATIENTS

*3 = good, 2 = fair, and 1 = poor.†2 = total, 1 = partial, and 0= none.

		No. of Digits Involved	Finger Transferred	Level of Amp. (Group⁷)	Vascular Structures Used				Kapandji Score²⁵	Cortical Integration†		Durat. of Follow-up
Case	Age	Artery	Vein	Nerve	Sensibility*	Function
	(Yrs.)											(Yrs.)
1	34	3	Index	2	Palmar(2)	Dorsal pedicle	Neurotization	3	8	2	Good	8
2	17	2	Index	2	Palmar(2)	Dorsal sutured vein	Neurotization	3	8	2	Good	8
3	38	3	Long	1	Dorsal	Dorsal vein sutured	Neurotization	3	7	2	Good	6
4	44	2	Index	1	Palmar(1)	Dorsal pedicle	Intact	3	8	2	Good	13
5	22	3	Index	1	Palmar(2)	Dorsal pedicle	Intact	3	8	2	Good	2
6	14	2	Index	2	Palmar(2)	Dorsal pedicle	Intact	3	8	2	Good	15
7	38	2	Index	2	Palmar(2)	Dorsal pedicle	Intact	2	6	2	Good	12
8	50	5	Index	3	Palmar(2)	Dorsal pedicle	Intact	3	6	2	Good	17
9	19	2	Index	2	Palmar(2)	Dorsal pedicle	Intact	3	7	2	Good	17
10	13	2	Index	2	Palmar(2)	Dorsal pedicle	Intact	3	7	2	Good	13
11	47	2	Index	3	Palmar(1)	Dorsal pedicle	Intact	2	5	1	Fair	7
12	29	4	Index	2	Dorsal	Dorsal pedicle	Intact	2	6	1	Fair	2
13	46	4	Long	3	Palmar(1)	Dorsal vein sutured	Intact	2	5	1	Fair	2
14	27	4	Index	2	Palmar(2)	Dorsal vein sutured	Intact	2	4	1	Fair	4
15	56	2	Index	2	Palmar(1)	Dorsal pedicle	Intact	2	5	1	Fair	9
16	41	5	Index	2	Palmar(1)	Dorsal pedicle	Intact	2	5	1	Fair	14
17	33	3	Long	2	Palmar(1)	Dorsal vein sutured	Intact	2	5	1	Fair	5
18	28	5	Index	2	Palmar(1)	Dorsal pedicle	Intact	2	4	1	Fair	12
19	50	2	Index	2	Palmar(2)	Dorsal pedicle	Intact	2	5	1	Fair	21
20	45	2	Index	2	Dorsal	Dorsal pedicle	Intact	2	4	1	Fair	10
21	25	3	Long	2	Palmar(2)	Dorsal vein sutured	Intact	2	5	1	Fair	12
22	35	5	Index	2	Palmar(2)	Dorsal pedicle	Intact	2	5	0	Poor	6
23	29	3	Ring	2	Palmar(2)	Dorsal pedicle	Intact	2	4	0	Poor	9
24	23	3	Index	2	Palmar(2)	Dorsal pedicle	Intact	2	4	0	Poor	10
25	56	5	Index	2	Palmar(2)	Dorsal pedicle	Intact	1	2	0	Poor	5
26	20	5	Index	2	Palmar(1)	Dorsal pedicle	Intact	1	4	0	Poor	5
27	37	2	Index	2	Palmar(2)	Dorsal pedicle	Intact	1	2	0	Poor	8

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TABLE I PREOPERATIVE AND POSTOPERATIVE CLINICAL DATA FOR THETWENTY-SEVEN PATIENTS

*3 = good, 2 = fair, and 1 = poor.†2 = total, 1 = partial, and 0= none.

		No. of Digits Involved	Finger Transferred	Level of Amp. (Group⁷)	Vascular Structures Used				Kapandji Score²⁵	Cortical Integration†		Durat. of Follow-up
Case	Age	Artery	Vein	Nerve	Sensibility*	Function
	(Yrs.)											(Yrs.)
1	34	3	Index	2	Palmar(2)	Dorsal pedicle	Neurotization	3	8	2	Good	8
2	17	2	Index	2	Palmar(2)	Dorsal sutured vein	Neurotization	3	8	2	Good	8
3	38	3	Long	1	Dorsal	Dorsal vein sutured	Neurotization	3	7	2	Good	6
4	44	2	Index	1	Palmar(1)	Dorsal pedicle	Intact	3	8	2	Good	13
5	22	3	Index	1	Palmar(2)	Dorsal pedicle	Intact	3	8	2	Good	2
6	14	2	Index	2	Palmar(2)	Dorsal pedicle	Intact	3	8	2	Good	15
7	38	2	Index	2	Palmar(2)	Dorsal pedicle	Intact	2	6	2	Good	12
8	50	5	Index	3	Palmar(2)	Dorsal pedicle	Intact	3	6	2	Good	17
9	19	2	Index	2	Palmar(2)	Dorsal pedicle	Intact	3	7	2	Good	17
10	13	2	Index	2	Palmar(2)	Dorsal pedicle	Intact	3	7	2	Good	13
11	47	2	Index	3	Palmar(1)	Dorsal pedicle	Intact	2	5	1	Fair	7
12	29	4	Index	2	Dorsal	Dorsal pedicle	Intact	2	6	1	Fair	2
13	46	4	Long	3	Palmar(1)	Dorsal vein sutured	Intact	2	5	1	Fair	2
14	27	4	Index	2	Palmar(2)	Dorsal vein sutured	Intact	2	4	1	Fair	4
15	56	2	Index	2	Palmar(1)	Dorsal pedicle	Intact	2	5	1	Fair	9
16	41	5	Index	2	Palmar(1)	Dorsal pedicle	Intact	2	5	1	Fair	14
17	33	3	Long	2	Palmar(1)	Dorsal vein sutured	Intact	2	5	1	Fair	5
18	28	5	Index	2	Palmar(1)	Dorsal pedicle	Intact	2	4	1	Fair	12
19	50	2	Index	2	Palmar(2)	Dorsal pedicle	Intact	2	5	1	Fair	21
20	45	2	Index	2	Dorsal	Dorsal pedicle	Intact	2	4	1	Fair	10
21	25	3	Long	2	Palmar(2)	Dorsal vein sutured	Intact	2	5	1	Fair	12
22	35	5	Index	2	Palmar(2)	Dorsal pedicle	Intact	2	5	0	Poor	6
23	29	3	Ring	2	Palmar(2)	Dorsal pedicle	Intact	2	4	0	Poor	9
24	23	3	Index	2	Palmar(2)	Dorsal pedicle	Intact	2	4	0	Poor	10
25	56	5	Index	2	Palmar(2)	Dorsal pedicle	Intact	1	2	0	Poor	5
26	20	5	Index	2	Palmar(1)	Dorsal pedicle	Intact	1	4	0	Poor	5
27	37	2	Index	2	Palmar(2)	Dorsal pedicle	Intact	1	2	0	Poor	8