Toe Transfers Outperform Replantation after Digit Amputations: Outcomes of 126 Toe Transfers

Background: The standard therapy after digital amputation is assumed to be replantation of the amputated digit. This study seeks to address - using validated functional outcomes in one of the world's largest series of toe transfers - whether toe transfers can match the function of replanted digits. This study also aimed to identify which physical variables improve functional outcomes after toe transfer. Methods: Seventy-five patients with 126 toe transfers were enrolled from 2015 to 2023 at Chang Gung Memorial Hospital, Linkou, Taiwan. The comparison group consisted of 52 patients with 96 digit replantations from the Finger Replantation and Amputation: Challenges in Assessing Impairment, Satisfaction, and Effectiveness (FRANCHISE) study, treated at the same center. The primary outcome was the Michigan Hand Outcomes Questionnaire (MHQ) score. Secondary outcome measures were the 36-Item Short Form Health Survey (SF-36) and Foot Function Index scores. Results: For toe transfers versus digital replantation, adjusted means revealed superior MHQ scores for toe transfers (75.7) compared with replantation (55.0) (P < 0.001), exceeding estimates of minimum clinically important differences. Pairwise comparisons noted that these differences increased with increasing severity of injury as stratified by the FRANCHISE classification. SF-36 scores were superior for toe transfers (55.79) versus replantation (53.22) (P = 0.008). On multivariable regression, factors influencing functional scores after toe transfer included moving 2-point discrimination, active range of motion, tripod grip, and SF-36 score, which all contributed significantly to the MHQ score (r2 = 0.55; P < 0.0001). Conclusions: These findings challenge current global approaches to digital amputation. In this study, toe transfers were shown to outperform equivalent digit replantations on validated patient-reported outcome measures. This has profound implications on the emergency provision of replantation, and the incorporation of elective toe transfer surgery into health frameworks. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.