Further Developments in the Twisted-Toe Technique for Isolated Thumb Reconstruction: Our Method of Choice

Background: Posttraumatic loss of the thumb is devastating. Toe-to-hand transfer is considered the criterion standard of reconstruction but is associated with donor-site issues. The twisted-toe technique uses parts from the great toe and the second toe, which allows for almost anatomical restoration of the donor foot. The authors present their experience and technical modifications of this method. Methods: Between January of 2003 and November of 2011, 18 patients suffering from loss of thumb because of a variety of indications were treated with the authors' modification of the twisted-toe technique. The neothumb was constructed with a partial onychocutaneous flap from the great toe and an osseotendinous flap from the second toe. Results: Of 18 transplanted twisted-toe flaps, 17 survived completely (5.6 percent flap loss rate). Similarity of the reconstructed thumb compared with the healthy side was very acceptable in all cases. All patients in whom the procedure was successful were able to use the neothumb in daily life without constraints. Reconstruction of the donor site yielded very acceptable outcomes with a distinct reduction in morbidity and disfigurement compared with conventional toe harvest. Conclusions: The modified twisted-toe technique is the authors' preferred choice of thumb reconstruction. It allows the reconstructive surgeon to construct a very natural-appearing neothumb with good stability and grip force. In addition, it eliminates many of the donor-site problems associated with pure great toe harvest, by recreating a "neo-great toe" at the donor foot. Although the procedure is more complicated and time-consuming compared with single toe harvest, the authors firmly believe that this extra effort takes thumb reconstruction to a next level.