Reconstruction of the thumb with microsurgical transfer of the big toe is now an accepted
approach. The expected outcome of such a procedure is a functioning digit, one that
not only looks like a thumb, but moves like a thumb and transmits sensory information
from the environment to the brain through its recovered sensibility. While the microsurgeon
is well-versed in “take backs” to salvage vascular problems after such a complex reconstruction,
there is nothing reported in the literature regarding salvage of the insensate hallux-to-thumb
transfer.
A 43-year-old man was presented who had a hallux-to-thumb transferred successfully
in March, 1999. By September, 2003, he had a thumb that had an excellent appearance,
excellent range of motion at its interphalangeal joint, but still had no perception
of touch on its dorsum, and only the perception of one-point moving and one-point
static touch on its pulp. There was poor localization of these simple perceptions.
At the initial operation, both plantar digital nerves had been connected to both digital
nerves, but no dorsal neurotizations were done. Restoration of sensation was accomplished
by resecting the in-continuity neuromas of the original two digital nerve reconstructions,
and then reconnecting the two digital nerves across the 1.5-cm resultant defects with
two bioabsorbable polyglycolic acid nerve conduits. Another 2.0-cm dorsal defect was
reconstructed between the deep peroneal nerve located in the transplanted hallux with
the radial sensory nerve. At 8 months after the neural reconstruction attempt, the
patient had excellent localization of dorsal and “thumb” pulp static touch sensations.
The patient received sensory re-education. The 15-month follow-up results for moving
and static two-point discrimination were presented. This was the first salvage procedure
for restoration of sensation reported for a hallux-to-thumb transfer.
