Toe Transfer Research Articles

Vascularized Toe and Nonvascularized Toe Phalangeal Transfer for Reconstruction of Congenital Absence of Digits or Thumb: A Systematic Review of the Literature

PURPOSE: Non-vascularized toe phalanx transplantation was first described to lengthen or reconstruct fingers, though criticized for high rates of avascular necrosis. More recently, vascularized transfer has improved graft survival, with adequate perfusion enabling increased growth. The aim of this study was to compare the indications, techniques, and outcomes of vascularized and nonvascularized toe-to-hand transfer surgery in patients with congenital hand differences. METHODS: A systematic review was conducted according to PRISMA guidelines. Studies containing data on indications, surgical technique, and outcomes for patients with congenital absence or deficiency of digits or thumb treated with toe-to-hand transfer were included. Confidence intervals (CI) were calculated for outcomes of the two toe transfer techniques. Failure was defined as resorption of the graft or necrosis necessitating removal. The 95% CIs were used to determine difference in outcomes. Statistical significance was determined using a chi-square test. RESULTS: Forty studies published between 1978 and 2020 were included, containing 534 patients and 866 transfers. Twenty-three studies (58%) described only vascularized/microsurgical toe-to-hand transfers, 15 (38%) described nonvascularized, and 2 (5%) included patients with both. There were 133 men (53.4%) and 116 (46.6%) women. Three hundred nineteen patients (59.7%) had vascularized transfers, 214 (40.1%) nonvascularized, and one had both (0.2%). The mean age for vascularized transfers was 2.5 years (range 6 months–17 years) and 3.1 years (range 6 months–22 years) for nonvascularized. Follow-up for the vascularized group was 4 months to 11 years and 6 months to 35 years in the nonvascularized group. Symbrachydactyly was the most common indication in both groups (46.3%, 45.3%). The most commonly transplanted vascularized toe was the second one (91.5%). The fourth toe was most commonly used in the nonvascularized group (61.9%). Vascularized toe transfers were most commonly used to reconstruct the thumb (53.3%) or unspecified fingers (25.9%). The thumb was also most commonly reconstructed in nonvascularized transfers (30%), followed by the middle (19.2%), ring and pinkie (17.8% each), and index finger (14.6%). In cases where hands were bilaterally affected, most often one vascularized toe was transferred to each affected hand (74%, second toe in 88% of these). For bilaterally affected patients in the non-vascularized group, 60% had one transfer to each hand (fourth and fifth toes preferred). Vascular complications were most common after vascularized transfers, occurring in 6.8% of transfers, though 94.7% of these were ultimately successful after reoperation. Resorption accounted for most complications after nonvascularized transfers, with a 12.6% resorption rate. The resorption rate was 0.7% in the vascularized group. Instability occurred after 5.6% of nonvascularized transfers and 0.7% of vascularized. Vascularized toes showed better healing, range of motion, and growth. In the vascularized group, there was a higher success rate of 98.6% (95% CI 97.4%–99.7%). The nonvascularized group had a success rate of 86.8% (95% CI 83.6%–90%), (P < 0.001). CONCLUSIONS: Both toe transfer techniques are good options for reconstruction of congenital absence or deficiency of digits or thumb. Our study found a higher success rate in vascularized compared with nonvascularized transfers. Indications and approach for each technique varied among patients treated by the same author.

Management of a mutilated hand: the current trends.

Mutilated upper limbs suffer loss of substance of various tissues with loss of prehension. The most important factor in salvage of a mutilated hand is involvement of a senior surgeon at the time of initial assessment and debridement. A regional block given on arrival helps through assessment and investigations in a pain-free state. Infection still remains the important negative determinant to outcome and is prevented by emergent radical debridement and early soft tissue cover. Radical debridement and secure skeletal stabilization must be achieved on day one in all situations. Dermal substitutes and negative pressure wound therapy are increasingly used but have not substituted regular soft tissue cover techniques. Ability to perform secondary procedures and the increased use of the reconstructed hand with time keeps reconstruction a better option than prosthesis fitting. Toe transfers and free functioning muscle transfers are the two major secondary procedures that have influenced outcomes.

Coverage of soft tissue defects in the thumb: Essential flaps in daily practice

Coverage of soft tissue defects in the thumb involves a variety of techniques ranging from simple second-intention healing to skin grafting with or without dermal substitutes, to local homodigital or heterodigital flaps and partial toe transfers. The arsenal in terms of skin coverage and especially flaps is very diverse. Our objective is not to make an exhaustive catalog of all the technical possibilities described in the literature, but rather to present in detail the options we have adopted in our daily practice. For each of these techniques, we present the rules for their implementation (anatomical bases, surgical techniques) and their topographical indications.

Comparative outcome analysis of osseointegrated reconstruction and replantation for digital amputations.

The long-term outcomes of osseointegration for digital amputations are not well established, and it is not known whether osseointegration can achieve similar function and patient satisfaction to conventional surgical options such as replantation and microsurgical toe transfer. We compared the long-term outcomes after digital osseointegration and replantation. Six patients treated by osseointegration and seven patients treated by replantation were included, with median follow-ups of 8 years and 4.6 years, respectively. Outcomes were assessed using the Michigan Hand Outcomes Questionnaire, grip and pinch strength, range of motion, two-point discrimination, Semmes-Weinstein tests, Jebsen-Taylor Hand Function Test and clinical photography. Osseointegration was associated with poorer sensibility and range of motion than replantation; no other differences reached statistical significance. Long-term osseointegration is a safe and effective reconstructive option that can deliver excellent outcomes in appropriately selected patients.Level of evidence: IV.

Versatility of the Posterior Interosseous Artery Flap: Emphasis on Powering Up the Toe Transfer.

Reverse-flow posterior interosseous artery (rPIA) flap is an excellent tool for restoration of defects in the hand and upper extremity, sparing the main arteries to the hand. Its reliability has been well established. Fifty-one cases of rPIA flap involving 49 patients were retrospectively reviewed. The inclusion criteria were age, sex, etiology, size and location of the defect, flap size, number of perforators included, pedicle length, flap inset, donor site coverage, complications, and ancillary procedures. This study included 44 men and 5 women, ranging in age between 10 and 73 years. The subjects had soft tissue defects of the hand and upper extremity mainly due to traumatic injuries, including scar contractures of the first web space in 18 cases, thumb amputations in 6 cases, and congenital defects in 1 case. Among the 51 rPIA flap elevations, 3 cases involved flap failure due to the absence of proper pedicle. A fasciocutaneous pattern was observed in 45 cases and a myocutaneous pattern in 3 cases. In 5 cases of unplantable thumb amputations, the rPIA flap was performed for arterial inflow to the secondary toe-to-thumb transfer. Venous congestion of varying degrees was noted in 7 cases involving partial necrosis in 2 cases. During the mean 17 months of follow-up, patients were generally satisfied with the final outcomes. The rPIA flap can be used not only for soft tissue coverage of the hand and upper extremity but also as a recipient arterial pedicle for a secondary toe-to thumb transfer.

Using 320-detector row computed tomography angiography to investigate the arterial anatomy of the toe flaps on living humans.

Using 320-detector row computed tomography angiography (320-CTA) to investigate the arterial supply for the toe flaps, namely the anatomical characteristics of the dorsalis pedis artery (DPA), the first dorsal metatarsal artery (FDMA), and the arteries of the first toe web space (AsFTWS). This was a prospective study on CTA of 72 intact feet of 36 Vietnamese adults who had sequelae of thumb or metacarpal hand amputation, from June 2017 to December 2019, then preoperative CTA images were compared with surgical findings on 31 feet of 29 patients. 320-CTA was able to investigate the DPA, FDMA, and AsFTWS in 100% of cases. DPA was absent in 6.9% of cases. The average diameters at its origin and termination were 3.22 and 2.56mm, respectively. For FDMA, the rates of Gilbert type I, II, and III were 52.8%, 18.1%, and 29.2%; the average diameters at its origin and termination were 1.98 and 1.67mm, respectively. At the first toe web space, FDMA was dominant in 54.2% of cases; the first plantar metatarsal artery (FPMA) was dominant in 29.2% of cases; both arteries were equally dominant in 16.6%. The average diameter at the origin of the lateral plantar digital artery of the great toe was 1.48mm, of the medial plantar digital artery of the second toe was 1.21mm. Preoperative CTA images resembled the surgical findings in all cases. The survival rate of toe flaps was 100%. The 320-CTA provided proper preoperative images in two and three dimensions, and helped surgeons to establish a preoperative surgical plan, thus increasing the success rate of toe transfer surgery.

Reconstruction of mutilating hand injuries by microsurgical free tissue transfers from the foot

IntroductionThe aim of this study is to present various hand reconstruction methods and provide technical notes regarding the treatment of mutilating hand injuries using free-tissue transfers from the foot and to investigate whether these transfers provide patients with a usable hand or not. Patients and MethodsNinety patients with mutilating hand injuries were included in the study. A total of 101 procedures were performed. Patients were contacted by phone to evaluate their working status and to record any complaints regarding their donor sites. The Quickdash questionnaire was conducted for the 53 patients who could be reached. Operative techniques, secondary procedures, finger survival, and physiotherapy data were noted retrospectively. ResultsIn 36 patients, a trimmed great toe was transferred to the thumb. Second toe-to-thumb transfers were performed in 8 patients, and second toe-to-finger transfers were performed in 10 patients. In 13 patients, 2 toes from one side were transferred, and in 6 patients, 3 toes were transferred to the hand. Bilateral toe transfers were performed in 9 patients. Eight patients underwent joint transfers, of which 2 involved joint transfers from both feet. The overall finger survival rate for the transfer procedures was 95.04%. The average Quickdash score of the patients who could be reached (n = 53) was 27.49, with 62.3% of the patients being able to use their hands in their previous jobs, and 26.4% needing to change their jobs because of their hand injuries. 41.5% of the patients had no donor site complaints. 47.2% had mild complaints, and 11.3% had major donor site complaints. ConclusionMultiple-toe transfer techniques along with flap coverage options should be considered, and delicate planning is mandatory to achieve at least a basic or acceptable hand. Three toes, including the great toe, can be transferred in a single operation by dissecting both the dorsal and plantar arterial systems. Crush injuries of the dorsal side of the hand may be reconstructed using combined transfers of bones, joints, extensor tendons, and skin. In our series, 88.7% of patients with mutilating hand injuries were able to return to work after we performed tissue transfers from the foot.

Salvage Reconstruction of a Congenital Hypoplastic Thumb Due to Constriction Ring Syndrome Using a Third Toe Transfer, When the Usual Donor Sites of Index Finger, Great and Second Toes Are Not Available.

Isolated third toe-to-thumb transfers have been rarely reported and none in the pediatric population. We describe a third toe-to-thumb transfer for reconstruction of a congenital hypoplastic thumb with excellent functional results and no morbidity in the donor foot.

The Clinical Results of Vascularized Second Toe Transfer for Traumatic Finger Loss Distal to the Proximal Interphalangeal Joint

The Clinical Results of Vascularized Second Toe Transfer for Traumatic Finger Loss Distal to the Proximal Interphalangeal Joint

Use of single-staged transmetatarsal trimmed great toe transfer for reconstruction of a thumb amputation at the carpometacarpal joint

Reconstruction for proximal thumb amputation at the carpometacarpal (CMC) joint level is extremely challenging. All thenar muscles are lost and other fingers might be lost or injured. Transmetatarsal trimmed great toe (TGT) transfer may be an option in such cases. Between 2012 and 2018, 11 patients who had amputation of the thumb at the CMC joint level were reconstructed by transmetatarsal TGT transfer in a single stage. There were seven cases in which the right hand was affected and four cases in which the left hand was affected. Three cases involved a contracture scar at the thumb stump and required web space reconstruction. Average follow-up was 33.9 months (range: 12-76 months) RESULTS: All toe transfers survived. The average of static two-point discrimination (S2PD) was 14.6 mm; the average scores of the Quick Disabilities of the Arm, Shoulder, and Hand (quickDASH) questionnaire and the Michigan Hand Outcomes Questionnaire (MHQ) were 18.6 and 73.8, respectively. Two cases did not achieve opposition due to mispositioning of the neothumb. In nine cases achieving opposition, the Kapandji score ranged from 4 to 9, pinch ranged from 3 to 11 lbs, and grip ranged from 15 to 86 lbs. In the donor foot, three patients had neuroma and two had a new callus on the palmar side of the second and third metatarsal heads. The average foot and ankle disability index score was 91.6. Single-staged transmetatarsal TGT transfer is safe and useful for thumb reconstruction at the CMC joint level. This reconstructive method is suitable for manual workers, especially in the developing countries.

The Role of Reverse Posterior Interosseous Artery Flap in Toe Transfer

BACKGROUND: Reverse posterior interosseous artery (rPIA) flap is an excellent tool for the restoration of defects in the hand and upper extremity. Its reliability and versatility are well established. Compared with the other forearm flaps, it spares the main arteries to the hand. Although very few case reports used the reverse radial forearm flap to provide arterial inflow for the toe-to-thumb transfer, the role rPIA flap in such cases has yet to be described. METHODS AND MATERIALS: Five procedures involving 4 patients performed by a single surgeon to power up a toe-to-thumb transfer were reviewed. In all the cases, the first dorsal metatarsal artery was anastomosed to the transposed proximal posterior interosseous artery. RESULTS: Three patients underwent unilateral reconstruction and 1 patient had bilateral thumb base reconstruction using rPIA flaps. Secondary toe-to-thumb transfers were performed at 1–7 months after mounding up the thumb base with rPIA flaps. All the flaps and toe transfers survived completely without any partial necrosis. All patients were satisfied with the functional outcome as well as the appearance of the thumb. CONCLUSION: The use of the proximal posterior interosseous artery pedicle in rPIA flap is a safe and reliable procedure especially in cases involving traumatic loss of the thumb. In addition to the simple soft tissue coverage around the thumb base, the rPIA flap also provides a satisfactory arterial inflow during subsequent toe-to-thumb transfer.

Combined Technique of Local Finger Flap and Partial Toe Flap for Finger Nail Reconstruction

BACKGROUND: Toe transfer operation for nail reconstruction of the hand is an established technique. However, although reconstruction of a cosmetic nail at the recipient site has become possible, the problem of the donor site in toes has not disappeared. The greatest problem of the conventional wrap-around flap method is a postoperative skin ulcer at the donor site of the toe because a large skin flap is harvested from the great toe and surgical dissection is invasive to the weight-bearing region. The authors have developed a new method for avoiding postoperative skin ulcer formation at the donor site. It consists of a combination of a finger flap elevated at the recipient site and a partial toe flap harvested from the great toe without dissecting the weight-bearing region. METHODS: A local finger flap is elevated at the recipient site and a partial toe flap including the nail is harvested from the great toe. They are combined to make a finger. Using this procedure, the size of the partial toe flap is slender and the weight-bearing region remains intact. The donor site wound is closed with artificial dermis once, and skin grafting is performed at 3 weeks after surgery. RESULTS: This procedure was performed in 31 fingers of 30 patients. In 2 smokers who were older than 60 years old, the partial toe flaps became necrotic but in the other 28 patients, flaps survived well and aesthetic fingertips were achieved. In all patients, the weight-bearing region of the great toe was intact and there was no trouble walking after surgery. CONCLUSION: Surgical invasion to the weight-bearing region may produce a skin ulcer postoperatively. However, the combination of a local finger flap and a partial toe flap results in a smaller skin defect of the great toe. This new concept of nail reconstruction is minimally invasive and simpler as a surgical technique.

Cosmetic and functional results of a newly reconstructed thumb by combining the phalanx of second toe and the great toenail flap transplantation

BackgroundMicrosurgical toe-to-hand transfer is a gold standard when it comes to repairing a thumb defect. Great toenail flap, thumbnail valva flap, free great toe, and second toe transplantation are the common methods in thumb reconstruction. Second toe transplantation achieves good function, but poor esthetics. Great toe transplantation achieves better esthetics, but hindered walking, due to the foot’s loss of the great toe and moreover suboptimal thumb function. It is difficult to maintain both functional and esthetic satisfaction in thumb reconstruction.MethodsWe experimented with three different methods of toe to hand transfer. From October 2009 to July 2019, 30 patients with traumatic thumb defects received one of 3 different kinds of thumb reconstruction in our clinic according to their level of amputation. Divided evenly into three groups of ten, group one received a great toe transplantation, group two received a second toe transplantation, and group three received a combined great toenail flap and second toe phalanx transplantation. Each of the patients’ thumbs had different levels of amputation at the metatarsophalangeal joint (MPJ) or distal interphalangeal joint (DIPJ).ResultsOne patient suffered from a partial flap necrosis and received a groin flap to cover the defect. No other thumbs had any complications. The functional and esthetic results of both the donor and the recipient sites were satisfactory. Results show that, for patients with traumatic thumb defects, the combined transfer of flap and second toe phalanx was the best option.ConclusionsCompared to the great toe or second toe transfer, combined free transfer of the great toenail flap and second toe phalanx achieved a substantially better functional and esthetic result in the thumb reconstruction.

Importance of preserving redundant pulp skin in thumb terminalization to allow subsequent reconstruction with on-top toe transfer: A clinical case (with video)

Traumatic thumb amputations can seriously jeopardise hand function. Several alternatives for reconstructing an opposable thumb have been described, including distraction osteogenesis, index finger pollicisation and free toe transfer. We present in this article the case of a young male patient that sustained a circular saw injury to his non-dominant thumb which resulted in loss of his distal phalanx. Preserving the sensate pulp allowed later reconstruction with an on-top free second toe transfer achieving a satisfactory outcome.

Crowdsourcing the aesthetics of thumb repair in pediatric thumb hypoplasia

Pediatric thumb hypoplasia is a group of congenital hand disorders encompassing gross underdevelopment or complete lack of a thumb. Index pollicization and toe transfer are both reasonable reconstructive options, and there is no clear consensus if either method provides a more functional or aesthetically pleasing result. Considering the psychological distress associated with poor cosmetic outcomes, aesthetics must be considered when choosing reconstructive method. A survey was generated using images of reconstructed thumbs from published papers and educational websites and posted on Amazon Mechanical Turk asking participants to rate the images on their overall aesthetic appearance, identify aesthetic features, rank thumbs according to what appears most natural, and answer a series of hypothetical functional questions. Responses were stratified by reconstruction type and analyzed with chi-square, two-sample t test, and linear regression analyses. Participants in the study were diverse across age, sex, ethnicity, and education. The average rating of the thumbs was 5.8 for index pollicization and 5.6 for toe transfer, ranging from 3.85–8.34 across both reconstructive types. Index pollicization was significantly associated with being ranked as “most natural” but neither reconstructive type was associated with being ranked as “least natural.” Aesthetic factors, including length, width, nail, and position of thumb significantly affected overall aesthetic score but only accounted for around 30% of the variation in overall score. There was no significant difference in response to hypothetical functional scenarios based on reconstructive type or dominant vs. non-dominant hand. Limitations of this study include the lack of granularity in crowdsourcing data and the lack of photographic standardization of the thumbs included in the survey. Reconstructive method should continue to be selected on an individual basis based on individual anatomy. Level of evidence: Not ratable

A management strategy for giant cell tumor of the metacarpal: A single-center series of 11 cases

BackgroundPrimary giant cell tumor (GCT) arising from bones of hand are rare to occur. Metacarpals are often the most common site of involvement among hand bones. There are no uniform guidelines for treatment of GCT involving metacarpals due to lack of relevant literature. ObjectiveTo suggest a management strategy for GCT involving metacarpals. MethodsRetrospective review of cases of GCT involving metacarpals over a period of 15 years from 2005 to 2019 managed at department of Orthopaedics, All India Institute of Medical Sciences, New Delhi. ResultsA total of 12 cases of GCT involving metacarpal were included, out of which one was lost to follow-up. Four cases were recurrent, and seven were primary at the time of surgery. All the patients were operated with wide excision of the tumor. In seven patients reconstruction of the metacarpal and MCPJ was done using fibular strut graft and silastic artificial joint, while in two patients, MCPJ arthrodesis was performed using fibula and/or iliac crest bone graft. In another two patients, the MCPJ was reconstructed using reversed vascularised toe transfer. Mean follow up of the patients was 3.22 ± 2.07 years. Mean Quick DASH score at latest follow-up of patients operated with silastic joint reconstruction, reversed vascularised toe transfer and arthrodesis of MCP joints were 30.5 ± 9.5, 25 ± 2.3 and 39.8 ± 3.4 respectively. Local recurrence occurred only in one patient at one year after surgery. All the patients were pain free at latest follow-up with quite functional and cosmetically acceptable hand. ConclusionReversed vascularised metatarsal transfer has obtained better functional results compared to reconstruction with fibular grafting and silicone joint replacement but due to technical difficulties, vascularised joint transfer may not be performed in every setting and there is risk of donor site morbidities with this technique. Our strategy for the treatment of GCT involving metacarpal was to do vascularised joint transfer or arthrodesis for border digits and reconstruction with silicone joint for central digits.

Non-vascularized toe phalanx transfer for correction of severe clinodactyly of the thumb in Rubinstein-Taybi syndrome.

In Rubinstein-Taybi syndrome, patients may have a particularly severe clinodactyly of the thumb. We evaluated a new method for correction of these severe clinodactylies using non-vascularized toe phalanx transfer as a replacement for the abnormal delta phalanx. Results of the new technique are presented, together with those of an osteotomy technique. We retrospectively recorded the angle of the clinodactyly before and after surgery and at long-term follow-up of 11 osteotomies and five transfers in nine patients from 1990 to 2017. The pre-operative angle of clinodactyli was similar between the two groups with a mean of 59°. After surgery, the correction was equivalent (7° and 11°). At the last follow-up (7 and 18 years), the relapse of clinodactyly was 17° for osteotomies and 1° for phalanx transfers. We noticed growth of the transferred phalanx, resulting in an excellent thumb length. We conclude that non-vascularized toe transfer can be an effective correction of severe clinodactyly and may be more stable than osteotomy in the long-term.Level of evidence: IV.

The Second Toe-to-Hand Transfer for Full-length Thumb Reconstruction in Congenital Thumb's Grade IIIb to V Hypoplasia: MTPJ Arthrodesis Instead of Tendon Rebalansing.

Congenital thumb hypoplasia is a rare deformity of the upper extremity. The classification of thumb hypoplasia was created by Blauth in 1967 (types I to V). The base of the first metacarpal bone is absent for hypoplasia types IIIb to V, therefore, toe-to-hand transplantation is not recommended. A stable first carpometacarpal joint has been considered a mandatory factor for a successful toe-to-hand transplantation. The aim of this study is to describe a new technique for thumb reconstruction with the second toe transfer and metatarsophalangeal joint (MTPJ) arthrodesis, which can provide a five-digit hand and restore thumb functionality for thumb hypoplasia IIIb to V. We performed second toe-to-hand transplantation with MTPJ arthrodesis for 3 pediatric patients (mean age, 69 mo) with congenital thumb hypoplasia IIIb (n=2), grade V (n=1). Long-term follow-up evaluated the functions and esthetics of the hands for grade IIIb patients (n=2). We believe the second toe transfer with MTPJ arthrodesis transplantation is a promising method for reconstructing a full-length congenital or traumatic thumb absence for the pediatric population.

Our surgical technique to treat premature growth plate closure 7 years after toe-to-thumb transfer. A case report

In children, traumatic distal amputations of the thumb can be treated by partial first toe transfer. Growth is preserved by conserving a portion of the growth plate in the hallux distal phalanx. In the patient featured here, 7 years after such a distal thumb reconstruction, bone bridge resection was needed to restart growth and correct clinodactyly. When this patient was reviewed 4 years later, the thumb's longitudinal growth had been restored and continued.

Immediate vs. delayed toe-to-thumb transfer: Is the infection rate greater?

After loss of a thumb, the big toe is a possible donor site for reconstruction with wrap-around free flap and trimmed-toe transfer techniques. Early reconstructions seem to reduce the risk of post-operative infections, despite several studies that show different infection rates of the recipient site in immediate toe-to-hand transfer. The authors carried out a retrospective analysis of their experience in thumb reconstruction with big toe transfer and evaluated the results achieved with both immediate and delayed reconstructions in terms of infection occurrence. From 2000 to 2017, patients who presented cut, crush and avulsion injuries in the thumb were selected and 33 toe-to-thumb transfers were performed. Patients were divided into two groups: in group A, patients underwent immediate reconstruction, while in group B delayed reconstructions were performed. The two groups received identical antimicrobial prophylaxis. Reliability of the immediate or delayed reconstruction was compared in terms of flap survival, requirement for a secondary intention healing and, in particular, rate of infection. 29 male and 4 female patients were treated. Toe-to-thumb transfers were performed in both groups: in group A, 8 wrap-around free flaps and 4 trimmed toe transfers; in group B, 11 wrap-around and 10 trimmed toe transfers. No flap loss occurred in either groups. No cases of infection were detected in the transferred toes. For toe-to-thumb transfer, there are published reports of a wide range of infection rates of the recipient sites. The authors compared their results in terms of infection rate between immediate reconstruction, group A, and delayed reconstruction, group B. Immediate toe-to-thumb transfer showed equal success rates to delayed transfer. No statistically significant difference in risk of infection between the two groups was found. Results showed that the immediate reconstruction was as safe and reliable as the delayed one.