The indications for thumb reconstruction using the great toe apply to the use of the second toe. 1-3 The second toe is used when the great toe is not acceptable as a donor site, for instance, when the patient will not accept a great-toe transplant. This occurs often in the Oriental population, where zori slippers are commonly worn. Another indication for using the second toe is when the level of amputation is through the proximal third of the first metacarpal and a significant length of metatarsal bone is necessary to provide adequate length in the reconstructed thumb. The second toe is also useful for reconstructing partial thumb loss through the interphalangeal joint, particularly in children.

Finger Reconstruction

Second-toe transplantation is indicated in a hand in which all fingers have been lost and there is no ulnar post against which the thumb can oppose. In this situation, two second-toe transplants may further increase the grip strength and ability to manipulate objects in the hand. When multiple fingers have been injured, but at least one or two digits remain as a post against which the thumb can oppose, the indications are less clear. Patients with either the long or ring fingers missing often have smaller objects fall through the gap during grasp. This disruption in the normal digital arcade is often unacceptable, especially in women.

Generally, ray amputation and/or transposition is preferred, but occasionally, to preserve strength and the breadth of the palm, second-toe transplantation is performed. 4 Singleor multiple-toe transplants may be of value in restoring appearance and function to congenitally missing or deformed fingers. With congenital amputations, all structures are present at the level of amputation, whereas with congenital agenesis, tendons, nerves, and vessels may be entirely missing. 5 Toes are particularly valuable in partial digital reconstruction because they are much shorter than fingers, and full digital length cannot be restored. The toenail is also considerably smaller than the fingernail, so even the best toe transplant, other than that of a large toe, will always appear smaller than adjacent normal digits. Additional nail length can be gained by cutting back on the proximal nail fold, exposing more of the nail plate. Patients can visualize what the final result will be by being shown the transplant on clay or plastic models.

Technical Considerations

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