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Le magazine de l’IFSSH interviewe le Dr Piñal à propos de son article sur la chirurgie reconstructive pour les pertes extrêmes de pouce pour ‘Plastic and Reconstructive Surgery’

18 février, 2021

IFSSH_Extreme Thumb Losses_01_20210212

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The work of the Spanish surgeon was distinguished last year with the PRS Best Paper Award for the best article in the hand category.

The February edition of the digital magazine of the International Federation of Societies for Surgery of the Hand (IFSSH) publishes an interview with Dr Francisco del Piñal, in which the Spanish surgeon presents the keys of his article on reconstructive surgery for extreme thumb losses for ‘Plastic and Reconstructive Surgery‘ (publication of the American Society of Plastic Surgeons, APS).

‘Extreme Thumb Losses: Reconstructive Strategies’ was honored last year with the PRS Best Paper Award for the best article in the hand category, among those published by the magazine of the US plastic surgeons society in 2019.

This paper by Dr Piñal presents new strategies to address proximal thumb amputations in a single step, using pre-existing muscles, free tissue transfer and toe to hand transplants (big toe or hallux), under the Switching-Two-Toe-Transfer (STTT) procedure, developed by the Spanish surgeon.

Switching-Two-Toe-Transfer procedure
The Switching-Two-Toe-Transfer procedure permits reconstruction of any length of missing thumb with a very benign donor site. Note that the MTP of the second toe is kept in its anatomic orientation and not rotated 180º as recommended in the literature; doing otherwise results in sideways instability (figure extracted from IFSSH Ezine Vol. 11 Issue 1 No. 41 pp. 42-44. February 2021)

In his interview for the IFSSH Ezine, Piñal defends his one-step procedure over the conventional approach of pollicitazion: “The literature recommends pollicization as the first-choice procedure, but my experience and beliefs were different”. “On one side -he says- patients much preferred to have five digits rather than four. Furthermore, rarely in my protected work-related environment would a patient return to work after a pollicization”. “In other words -continues Piñal- “patients were both unhappy and unfit to work by current standards”.

In this clinical context, the use of hallux to restore missing length in proximal thumb amputations generated a very high impact on the donor foot. In order to solve this problem, Piñal developed the STTT (a variation of the original Foucher’s technique) approximately two decades ago, “with the advantages of providing a ‘big-thumb’ of any length and with limited donor site sequela”.

Thumb reconstruction in the subacute period
The use of the STTT in a case of missing thumb at the base of the proximal metacarpal. The reconstruction was carried out in the subacute period, thus some of the intrinsic muscles could be used, providing a stable thumb (image extracted from IFSSH Ezine Vol. 11 Issue 1 No. 41 pp. 42-44. February 2021).

Likewise, Dr Piñal emphasizes the importance of early reconstructions “to get the most out of what was left after the traumatic event”: “We have seen that delaying reconstructions -he insists- causes tendon transfers or arthrodesis (that is, joint fusions) inevitable”.

Asked what every surgeon or hand therapist who reads his article for ‘Plastic and Reconstructive Surgery’ should understand, Piñal affirms that the “most important” message he wanted to convey is that “proximal thumb amputations benefit enormously from reconstruction with great toes”.

During his interview, the Spanish surgeon once again stressed the need to involve the patient in the process: “As proximal injuries are often combined injuries, a plan needs to be laid down so that the patient understands the steps that will be taken and why . Patient participation eases the sufferance associated with these devastating injuries and increases cooperation”.

Reconstruction in amputation at the trapezoid level
In this case of amputation at the trapezoid level, in a single-stage the thumb was reconstructed and the patient was able to pinch 9 weeks after the reconstruction (image extracted from IFSSH Ezine Vol. 11 Issue 1 No. 41 pp. 42-44. February 2021).

Extreme thumb losses

As a background to the PRS Best Paper Award-winning article, Dr. Piñal notes how complex thumb amputations have historically been managed in two phases, and often require soft tissue and tendon transfer to achieve satisfactory results.

In his presentation of innovative strategies to deal with this type of injury, the Spanish surgeon considers that proximal thumb amputations go beyond the “simple” loss of a finger, grouping them under the denomination of extreme thumb reconstructions due to their complexity.

In order to evaluate the immediate reconstruction of the thumb in a single step, Piñal’s work analyzes the cases of 24 patients (from a series of more than 500 toe-to-hand transplants) to validate this approach. All of them rated the functional and cosmetic results of their procedures on a scale of 0 to 10, with an average of 8.5 and 8.4, respectively.

In his conclusions, Piñal states that in cases of thumb amputation, the surgeon should pay attention not only to the loss of the thumb per se, but also to the first web and the thenar muscles, among other variables. In turn, he recommends abandoning the standard practice of using pedicled groin flaps followed by toe-to-hand transfer, otherwise, he states, “the thenar muscles become useless, the first metacarpal contracts and the need for tendon transfers skyrockets”.

Case study of ‘Extreme Thumb Losses: Reconstructive Strategies'
// In the image above, one of the case studies of the article. The (23 years old) patient’s hand was trapped in a rolling hot press device. At the end of the composition, we see him grabbing a 3.5 kg bottle filled with sand with the affected hand, one year after the microsurgical procedure (image extracted from ‘Extreme Thumb Losses: Reconstructive Strategies’,’Plastic and Reconstructive Surgery’ 144(3):665-677, September 2019 – Copyright © 2019 American Society of Plastic Surgeons.).

The Spanish surgeon has performed more than 500 toe to hand transfers, constituting a world reference in this type of microsurgical procedure. Born in 1960 in Santander, Dr Francisco del Piñal is considered one of the world’s best hand surgeons.

Full interview at https://www.ifssh.info/pdf/issue-41-february-2021.pdf pp. 42-44

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