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There are situations in which amputated hands or fingers cannot be replanted directly back to their original positions. When there is severe segmental injury across the hand and wrist but one or several fingers are still healthy, the fingers can be selected to be replanted at the forearm bones to restore pinch function. This is different from the toe to antebrachial stump transplantation presented by Dr. Vilkki. From the results in four patients, the following conclusions are drawn: (1) When the fingers are replanted at the forearm bone(s), only pinch function can be obtained. There is no opposition. (2) Grip function is weak because the intrinsics are lost and only a few fingers are replanted. The forearm bones are often shortened, as are the flexors. (3) Of particular importance is the creation of a large web space between the radial digit and ulnar digit(s), because fingers are longer than toes. (4) The sensory recovery is not so good as in ordinary finger replantation. However, this is a salvage procedure. Regardless of these facts, the patients are still satisfied with the results out of such severe injuries. With good pinch function, not only are they independent in daily life, but they also can do a lot of work. It is a worthwhile procedure. A functional prosthesis can be added distally after this replantation.

The microsurgical second toe wrap-around technique is an ideal treatment option for reconstruction of the distal half of the finger with circumferential loss of skin and nail associated with an uninjured proximal interphalangeal joint and an intact insertion of the flexor digitorum superficialis tendon. Follow-up of 13 flaps in 10 patients from 1986 to 1989 demonstrates rapid and adequate functional recovery as well as satisfactory aesthetic appearance in all patients.

After the loss of four fingers at the metacarpal level, triple toe transfer from the same foot was performed in the dominant hand of an art worker who needed three ulnar digits to work with the intact thumb. The toes of the left foot could not be used because of a previous injury. Long-term follow-up at 3 years showed good results in terms of function. He regained dexterity for calligraphy, notably the brush calligraphy and painting that are important in his job. The donor site was treated very carefully to prevent complications. There was minimal donor site morbidity. He still can walk very well and runs fast. Gait analysis of the donor foot is presented. This was a unique situation, and satisfactory results were obtained through the cooperation of the patient as well as detailed analysis before surgery.

Our experience with simultaneous transfer of two or more toe units to the same hand where multiple digits were missing is presented. Forty-six toes from 38 feet were transferred to reconstruct 19 hands in 19 patients. The transfers consisted of 7 combined second and third toe units and 32 single toes. Three patients had a primary and 16 patients had a secondary reconstruction. There was one complete and one partial failure. The two-point discrimination ranged from 6 mm to protective sensation. Total active movement averaged 57 degrees in the thumb and 127, 93, 71, and 68 degrees, respectively, in the fingers reconstructed at middle phalanx, proximal phalanx, metacarpophalangeal joint, and metacarpal head. Pulp-to-pulp pinch averaged 2.4 kg in patients who had thumbs reconstructed and averaged 3.0 kg in patients who had normal thumbs. There was no cold intolerance, and no significantly disabled foot occurred except one with scissoring deformity. Simultaneous multiple toe transfer in hand reconstruction is feasible without increased complications both in primary and secondary wound conditions. It is time-effective and cost-effective.

Historically, restoration of hand function following multiple digital amputation has been unsatisfactory. The evolution of digital reconstruction with toe transfer has enabled surgeons to reestablish prehension in these severely injured hands. A 4-year experience with 26 consecutive combined second and third toe transfers to replace missing adjacent fingers was reviewed in order to delineate the indications and technical considerations and to emphasize prevention of donor-site complications. Combined second and third toe transfer is reserved for adjacent finger amputations proximal to the digital web space with remaining fingers no longer than the small finger. Radial amputations are replaced with contralateral combined toe units, while ipsilateral toes are more ideal for ulnar amputations. Limited dorsal and plantar skin flaps extending only to the midpoint of the first and third digital web spaces allow for direct donor-site closure and uncomplicated healing. Maintenance of the plantar metatarsal arch by avoiding metatarsal shaft osteotomies or bone grafting-shortened metatarsals eliminates potential gait disturbances. When properly applied in selected patients, this single-stage microsurgical procedure can restore prehensile function, improve the appearance of the hand with multiple digital amputations, and preserve near-normal donor-foot function.

Reconstruction of all four fingers that were amputated at the metacarpophalangeal (MP) joints of the right hand of a 17-year-old male patient was performed by simultaneous transfer of the combined second and third toes from each foot at the level of the metatarsophalangeal joint. Fifteen-month follow-up showed acceptable cosmesis with satisfactory functional results. The patient had no foot discomfort, even after prolonged walking and running.