Reply: Extreme Thumb Losses: Reconstructive Strategies

Sir: Dr. AL Deek’s comments and insight, as a senior trainee of a much-respected team on the matter, are very much welcomed. I like the ferocity of the letter, but there are several things that need a tempered discussion. Limitations. I let the reader judge what is best in each situation, but even in cases of absence of trapezium and muscles, the results are far faster in our “nonclassic” approach (Fig. 1). I should remark that for proximal defects, when pedicled osteocutaneous groin flaps were used, fewer than half of the patients completed the reconstruction1—an undesirable end, understandable when the reconstruction process is long or protracted. Contrarily, all my patients completed the reconstruction.Fig. 1.: In this proximal amputation, which included the scaphoid (case 3), all of the reconstruction was performed in one stage. The patient was able to pinch at 9 weeks.“Not applicable.” I should clarify that all but one could tip-pinch or tripod pinch. Perhaps Dr. AL Deek’s confusion arises from the misleading use of the Kapandji opposition score for metacarpal hand reconstructions (thus “not applicable”). This was explained on page 669 of my article.2 Allotransplantation. Personally, it is not a matter of thinking inside or outside the box, but a matter of immunology. Technically, we have been prepared for years for any “bit” transplantation. To stage or not. I dislike the idea of my own hand being hooked to my groin for 3 weeks. Furthermore, if there is any muscle left to be salvaged, by waiting, this will be lost. So, despite the policy of Chang Gung Memorial Hospital, I still stick to my guns. Metatarsophalangeal/metacarpophalangeal joint. In the article, I wanted to stress the importance not only of joints, but also of having motors to control them to prevent thumb collapse. Nonetheless, my results of metatarsophalangeal joint transfers to the hand are better than what the author states, provided the joint is not rotated 180 degrees.3 Nevertheless, even assuming his figure of 34 degrees, that arc is still quite satisfactory, as the average motion of metacarpophalangeal of the thumb is 50 degrees.4 Sequence. Despite the low risk (three failures in my 508 cases), I prefer thumb reconstruction first, with the other foot in reserve should the first transfer fail. Doing it the other way may place the surgeon in the uneasy situation of toes in the finger position and nothing to oppose with. The choice. Finally, as the saying goes, “horses for courses”: there is no room for saying the only method. Pioneers such as Wei, Taylor, Morrison, Buncke, and others made such refinements that we can only add small changes, but I definitely think that “a little is a lot.” Long before Dr. AL Deek’s article on metacarpal-like injuries, we published the way to handle them, where to plant the toes, and why.5,6 Readers are referred there, but I will stress the importance of searching for the acceptable hand: a hand with a thumb and three fingers, that is as long as possible, with functioning proximal interphalangeal joints, and that can be used to restore a harmonious arcade. Again, Dr. AL Deek’s letter is much appreciated, as hand surgery definitely benefits from such discussion and impetus from below is much needed, but also from the humility to accept that there may be a better-different world. DISCLOSURE The author has no financial interest to declare in relation to the content of this communication.