Scientific article| Volume 45, ISSUE 2, P154.e1-154.e7, February 2020

Long-Term Donor-Site Morbidity After Free, Nonvascularized Toe Phalanx Transfer for Congenital Differences of the Hand


      Toe phalanx transplantation is a well-established technique for addressing bony deficiency in the reconstruction of hypoplastic digits in patients with congenital differences of the hand. Prior studies have commented on varying degrees of donor-site morbidity, although assessment of morbidity with validated outcome scores is lacking. This study seeks to evaluate donor-site morbidity after toe phalanx harvest using validated outcome measures.


      We identified all children who underwent free, nonvascularized toe phalanx transfer to the hand at our institution from 2001 to 2011. We administered the Oxford Ankle Foot Questionnaire for Children (OXAFQ-C) and the Foot and Ankle Ability Measure (FAAM) to all patients, scaling results according to published scoring instructions.


      Thirty-six patients with 83 toe phalanx transfers were able to be contacted, with a mean follow-up of 5.3 years (range, 18 months–11.2 years). The results of the OXAFQ-C showed mean scores of 99.96% (Physical), 100% (School and Play), and 96.01% (Emotional). The FAAM mean scores were 99.08% (Sports) and 99.17% (Activities of Daily Living). There were no lower extremity complications during the study period.


      In contrast to varying degrees of donor-site morbidity reported in the current literature, this study demonstrates that toe phalanx harvest causes almost no measurable lower extremity morbidity or dysfunction over the mid- to long-term.

      Type of study/level of evidence

      Therapeutic IV.

      Key words

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        • Matsuno T.
        • Ishida O.
        • Sunagawa T.
        • Ichikawa M.
        • Ikuta Y.
        • Ochi M.
        Bone lengthening for congenital differences of the hands and digits in children.
        J Hand Surg Br. 2004; 29: 712-719
        • Netscher D.T.
        • Lewis E.V.
        Technique of nonvascularized toe phalangeal transfer and distraction lengthening in the treatment of multiple digit symbrachydactyly.
        Tech Hand Up Extrem Surg. 2008; 12: 114-120
        • Netscher D.T.
        • Richards W.T.
        Rational treatment for multiple digit congenital absence: case report of nonvascularized toe phalangeal transfers and distraction lengthening for symbrachydactyly.
        Ann Plast Surg. 2006; 56: 211-215
        • Patterson R.W.
        • Seitz Jr., W.H.
        Nonvascularized toe phalangeal transfer and distraction lengthening for symbrachydactyly.
        J Hand Surg Am. 2010; 35: 652-658
        • Seitz Jr., W.H.
        • Dobyns J.H.
        Digital lengthening. With emphasis on distraction osteogenesis in the upper limb.
        Hand Clin. 1993; 9: 699-706
        • Seitz Jr., W.H.
        • Froimson A.I.
        Callotasis lengthening in the upper extremity: indications, techniques, and pitfalls.
        J Hand Surg Am. 1991; 16: 932-939
        • Seitz Jr., W.H.
        • Shimko P.
        • Patterson R.W.
        Long-term results of callus distraction-lengthening in the hand and upper extremity for traumatic and congenital skeletal deficiencies.
        J Bone Joint Surg Am. 2010; 92: 47-58
        • Gohla T.
        • Metz C.H.
        • Lanz U.
        Non-vascularized free toe phalanx transplantation in the treatment of symbrachydactyly and constriction ring syndrome.
        J Hand Surg Br. 2005; 30: 446-451
        • James M.A.
        • Durkin R.C.
        Nonvascularized toe proximal phalanx transfers in the treatment of aphalangia.
        Hand Clin. 1998; 14: 1-15
        • Toby E.B.
        • Koman L.A.
        • Poehling G.C.
        Extraperiosteal toe phalanx transfer for congenital aphalangia: refinement of technique.
        Orthopedics. 1990; 13: 1371-1373
        • Cavallo A.V.
        • Smith P.J.
        • Morley S.
        • Morsi A.W.
        Non-vascularized free toe phalanx transfers in congenital hand deformities--the Great Ormond Street experience.
        J Hand Surg Br. 2003; 28: 520-527
        • Garagnani L.
        • Gibson M.
        • Smith P.J.
        • Smith G.D.
        Long-term donor site morbidity after free nonvascularized toe phalangeal transfer.
        J Hand Surg Am. 2012; 37: 764-774
        • Leca J.B.
        • Auquit Auckbur I.
        • Bachy B.
        • Milliez P.Y.
        Non vascularized toe phalangeal transfers for symbrachydactyly. Active range of motion without joint reconstruction [in French].
        Ann Chir Plast Esthet. 2008; 53: 513-516
        • Ozkan T.
        • Kuvat S.V.
        • Aydin A.
        • Biçer A.
        Nonvascular phalangeal transfer from toes to hand in congenital aphalangia [in Turkish].
        Acta Orthop Traumatol Turc. 2007; 41: 36-41
        • Radocha R.F.
        • Netscher D.
        • Kleinert H.E.
        Toe phalangeal grafts in congenital hand anomalies.
        J Hand Surg Am. 1993; 18: 833-841
        • Tonkin M.A.
        • Deva A.K.
        • Filan S.L.
        Long term follow-up of composite non-vascularized toe phalanx transfers for aphalangia.
        J Hand Surg Br. 2005; 30: 452-458
        • Unglaub F.
        • Lanz U.
        • Hahn P.
        Outcome analysis, including patient and parental satisfaction, regarding nonvascularized free toe phalanx transfer in congenital hand deformities.
        Ann Plast Surg. 2006; 56: 87-92
        • Morris C.
        • Doll H.
        • Davies N.
        • Wainwright A.
        • Theologis T.
        • Willett K.
        • Fitzpatrick R.
        The Oxford Ankle Foot Questionnaire for children: responsiveness and longitudinal validity.
        Qual Life Res. 2009; 18: 1367-1376
        • Morris C.
        • Doll H.
        • Wainwright A.
        • Davies N.
        • Theologis T.
        • Fitzpatrick R.
        The Oxford Ankle Foot Questionnaire for Children: review of development and potential applications.
        Prosthet Orthot Int. 2010; 34: 238-244
        • Morris C.
        • Doll H.
        • Wainwright A.
        • Theologis T.
        • Fitzpatrick R.
        The Oxford ankle foot questionnaire for children: scaling, reliability and validity.
        J Bone Joint Surg Br. 2008; 90: 1451-1456
        • Morris C.
        • Liabo K.
        • Wright P.
        • Fitzpatrick R.
        Development of the Oxford ankle foot questionnaire: finding out how children are affected by foot and ankle problems.
        Child Care Health Dev. 2007; 33: 559-568
        • Martin R.L.
        • Irrgang J.J.
        • Burdett R.G.
        • Conti S.F.
        • Van Swearingen J.M.
        Evidence of validity for the Foot and Ankle Ability Measure (FAAM).
        Foot Ankle Int. 2005; 26: 968-983
        • Buck-Gramcko D.
        The role of nonvascularized toe phalanx transplantation.
        Hand Clin. 1990; 6: 643-659