Cleft Hand/Foot Toe-to-Hand Transfer: A Review of 18 Transfers in 14 Patients
Erin M Taylor, MD1,2; Joseph Upton, MD2,3
1Boston Children's Hospital, Boston, MA, 2Shriners Hospital for Children, Boston, MA, 3Department of Plastic Surgery, Boston Children's Hospital, Boston, MA
Introduction: Cleft Hand/Foot anomalies present a unique challenge for the reconstructive microsurgeon. Patients with cleft hand have absence of one or more digits, or often monodactyly, with associated limitations in hand function. Hand reconstruction with toe or duplicated digit transfer is challenging but worthwhile given significant improvement in function. We present our experience of 18 transfers in cleft hand/foot patients.
Materials & Methods: A review of 18 transfers in 14 patients with cleft hand/foot was performed. All patients underwent transfers by the senior author between the years of 1999-2018 at one of two pediatric hospitals (Boston Children's Hospital; Shriners Hospital for Children, Boston). Patient characteristics, indication for toe transfer, associated syndromes, recipient site, need for bone fixation, presence of syndactyly, monodactyly, superdigit, ray deficiency, or transverse bones, and complications were evaluated.
Results: Eighteen transfers were performed in 14 patients. The study patient population had a mean age of 6 years (r, 2-18), with a trend of transfers occurring earlier. Associated syndromes included Ectrodactyly-ectodermal dysplasia-clefting (EEC) syndrome, present in 7/14 patients, and Goltz Syndrome, present in 1/14 patients. Monodactyly hands were recipients in 10/18 transfers. Donor digits included most commonly the fifth toe (9/18) followed by the great toe (4/18), thumb polydactyly (4/18), and second toe (1/18). Syndactyly was present in 7/18 transfers. Superdigit was present in 3/18 transfers. Transverse bones were present in 7/18 transfers. Bone fixation was required in 16/18 transfers. Two transfers had complications, including one foot donor site skin graft with poor take and one great toe transfer with bone non-union to the recipient site. In review of the 18 cases, technical caveats included preservation of metatarsal length of donor toe, bone fixation for stability at recipient site, and the presence of recipient structures despite unique anatomy. All patients had improved functional results and low donor-site morbidity.
Conclusions: Our review of cleft hand/foot toe-to-hand transfers provides the largest series of transfers specific to cleft hand/foot patients in the literature. Half of the patients had syndrome diagnoses, and more than half of the patients had monodactyly. The cases are technically difficult due to small structures and unique anatomy; however, the functional results are remarkable due to the adaptability of young patients.
Figure 1: Fifth toe transfer in cleft hand/foot syndrome patient with monodactyly, which was the most common yet technically challenging of transfers.
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