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PubMed1999

Reconstruction of bilateral metacarpal hands with multiple-toe transplantations.

Bilateral metacarpal hands, if not treated properly, leave a patient without prehensile ability in both hands. Since 1990, six patients with bilateral metacarpal hands caused by accidents have undergone reconstruction with multiple-toe transplantations. Four or five toes were used for each patient, with a total of 27 toes transplanted to the hands. There was no toe loss. One nonunion in a middle-finger reconstruction was treated successfully with bone grafting. Secondary operations for functional improvement included one joint fusion and one flexor tendon tenolysis. Only one patient required excision of a plantar callus 42 months postoperatively, whereas the other five patients reported no major donor-site problems in an average 57 months of follow-up time. The six patients continue all their daily activities independently. Although their jobs were changed, all adult male patients were able to return to regular work. Principles of reconstruction to achieve satisfying prehensile function combined with minor donor-site morbidity in bilateral metacarpal hands include an adequate soft-tissue coverage before toe transplantations, selection of digits to be reconstructed based on functional and individual requirements, selection of toes and number of toes to be harvested based on consideration of usefulness for the hands and of foot morbidity, and consideration of thenar function in planning the sequence of transplantations. In conclusion, given thorough planning, multiple toe-to-hand transplantations can provide adequate prehensile function in reconstructed bilateral metacarpal hands with acceptable donor-site morbidity.

Adult↗

PubMed1998

"Extensor toe sign" by various methods in spastic children with cerebral palsy.

Upper motor neuron lesion in adults is usually associated with spasticity and "extensor toe sign" on plantar stimulation (extensor plantar response). There are various methods of eliciting this sign including the classic method by Babinski. Other methods produce this response when the area of reflexogenic zone is increased due to upper motor neuron lesion. There are varying reports of Babinski positivity in spastic cerebral palsy. This study was undertaken to assess the sensitivity of different methods of eliciting "extensor toe sign." An attempt has also been made to correlate the severity of spasticity with the combined "extensor toe sign" positivity by various methods and with the increase in reflexogenic zone. Eighty-one children with spastic cerebral palsy were examined. Twelve had hemiplegia; therefore, a total of 150 limbs were tested. "Extensor toe sign" was elicited by 12 different methods in each patient. The sensitivity of each method was calculated and compared with each other one. The assessment of spasticity was done using the Ashworth Tone Scale. The severity of spasticity was correlated with "extensor toe sign" positivity using various methods. Classic Babinski reflex was positive in 75% of cases, whereas Gonda-Allen sign was positive in 90% of cases followed by Allen-Cleckley (82%), Chaddock (74%), and Cornell (54%). All other signs had sensitivity of less than 30%. There was no increase in sensitivity after combining them. There was significant negative correlation between the spasticity and the combined "extensor toe sign" positivity (by all the methods). This study, therefore, suggests that the majority of patients with spastic cerebral palsy have positive "extensor toe sign." The Gonda-Allen method is more sensitive than the classic Babinski method. A positive "extensor toe sign" is negatively correlated to the degree of spasticity.

Adolescent↗

PubMed2006

Reliability and validity of the American Orthopaedic Foot and Ankle Society Clinical Rating Scale: a pilot study for the hallux and lesser toes.

BACKGROUND: The use of clinical outcomes instruments is essential for the effective interpretation of individual patient progress as well as the comparison of treatment groups. An outcomes instrument must be reliable and valid to obtain any meaningful data. The purpose of the present study was to examine the reliability and validity of the American Orthopaedic Foot and Ankle Society (AOFAS) clinical rating scale for the hallux metatarsophalangeal-interphalangeal and lesser toes metatarsophalangeal-interphalangeal joints. METHODS: Eleven patients (one man, 10 women) with an average age of 54 (range 40 to 72) years and with classic rheumatoid arthritis not currently treated for foot complaints were enrolled in the present study. The average duration of rheumatoid arthritis was 14 years. Each patient completed a set of two outcomes instruments and had a physical examination by a single clinician at the initial visit and returned at 1 week for completion of the same scales and examination. The outcomes scales used were the AOFAS clinical rating scale for the hallux, the AOFAS clinical rating scale for the lesser toes, and the previously validated Foot Function Index (FFI). Test-retest reliability was evaluated using intraclass correlation coefficients between week 1 and week 2 for the summary scores as well as for the subscales of pain and activity. Consistency between the two instruments was evaluated with Pearson correlation coefficients. RESULTS: The AOFAS clinical rating scale for the hallux and lesser toes is repeatable between 1-week trials (ICC 0.95; p < 0.05; ICC 0.80; p < 0.05, respectively). Moderately strong correlations were found between the mean values for the AOFAS hallux and FFI (r = -0.81; p < 0.05). Weaker correlations were seen between the mean values for the AOFAS lesser toes and FFI scales (r = -0.69; p < 0.05). CONCLUSIONS: The hallux subscale for pain correlates strongly with the FFI subscale for pain, suggesting high content validity (r = -0.94; p < 0.001). Ceiling effects were seen with the AOFAS lesser toe subscale for activity, limiting its usefulness in a general patient population. The AOFAS lesser toe subscale for pain and the AOFAS hallux subscale for activity correlated weakly with the FFI values (r = -0.31; r = -0.37; p > 0.05, respectively). CONCLUSIONS: Although the AOFAS hallux and lesser toe scales were found to be reliable in a rheumatoid patient population, their validity remains in question. These findings must be confirmed with larger subject numbers, with the inclusion of symptomatic patients before recommended routine use of the hallux clinical rating and lesser toe clinical rating scales.

Adult↗

PubMed1998

Triggering of the lesser toes at a previously undescribed distal pulley system.

We have treated five patients with metatarsalgia and triggering of the lesser toes. This paper describes a mechanism of triggering that involves a previously undescribed flexor pulley system in the toes that is very similar to the pulley system in the fingers. The specific anatomy of the toe flexor pulleys is described based upon the dissections of 50 fresh-frozen cadaver toes. These pulleys were composed of transverse to obliquely oriented fibrous bands within the flexor sheaths from the metatarsal heads to the distal phalanges. We found a system of pulleys in the lesser toes and the great toe, analogous to that found in the hand. Trigger toe is a rare entity and is only briefly described in the literature. We believe it is more common than is now recognized and may be an important underdiagnosed cause of metatarsalgia. The diagnosis is made when active plantarflexion causes the toes to catch in flexion and the patient is then unable to extend them. Nonsurgical therapy consisting of steroid injection, NSAIDs, or changing footwear may be effective, otherwise surgical release of the A1 pulley may be required.

Adult↗

PubMed2000

Compensatory advantages of toe walking.

OBJECTIVES: The study's hypothesis is that toe walking requires less peak muscle strength distally about the ankle and knee compared with normal heel-toe walking and thus may have compensatory advantages for patients with upper motor neuron injury and distal muscle weakness. DESIGN: Motion analysis and force platform data were collected in able-bodied subjects during toe walking and normal walking. Sagittal plane joint torques reflecting muscle force requirements and joint powers reflecting nonisometric muscle contraction were compared between the two conditions using paired t tests, applying a Bonferroni correction for multiple comparisons. SETTING: A gait laboratory. SUBJECTS: Seventeen able-bodied adults, 9 of whom were ballet dancers. MAIN OUTCOME MEASURES: Peak hip, knee, and ankle joint torque and power variables during walking. RESULTS: Peak ankle plantarflexor torque and ankle power generation during terminal stance and preswing were reduced (p<.001), as compared with normal heel-toe walking. The normal ankle dorsiflexor torque at initial contact-and the knee extensor torque and knee power generation during loading response were all essentially absent during toe walking. Hip extensor torque and hip power generation during the loading response phase were greater for toe walking (p<.001). CONCLUSION: Toe walking may require less ankle plantarflexor, ankle dorsiflexor, and knee extensor strength than normal heel-toe walking and thus may have compensatory advantages for patients with upper motor neuron injury and distal lower extremity weakness.

Adult↗

PubMed2005

Role of toe flexor tendoscopy in management of an unusual cause of metatarsalgia.

The purpose of this study is to describe an endoscopic approach to toe flexor tendons at the level of metatarsal head region. And this study is a kind of retrospective case series. Three patients with toe flexor tenosynovitis were evaluated after a follow-up of 2 years after toe flexor tendoscopy. One patient suffered from infective toe flexor tendosynovitis resulting from a penetrating injury and other two patients suffered from idiopathic focal toe flexor tenosynovitis. Pre-operative metatarsalgia subsided after toe flexor tendoscopy. No endoscopy-related complication was observed. Toe flexor tendoscopy can be an effective operative means in the management of focal toe flexor tenosynovitis.

Adult↗

PubMed2001

Can toe-walking contribute to stiff-legged gait?

OBJECTIVE: Spastic paretic stiff-legged gait, defined as reduced knee flexion in swing, has previously been attributed solely to spastic quadriceps activity. In earlier work, the authors suggested that reduced knee flexion in swing can be attributed to other indirect factors, such as poor hip flexion and abnormal foot-ankle function during gait. The present study was undertaken to determine whether toe-walking, which often occurs in conjunction with stiff-legged gait, in and of itself, might explain some of the reduced knee flexion in swing. DESIGN: An analysis was performed of three-dimensional kinematic data collected from able-bodied subjects while walking on their toes vs. normal heel-toe walking. RESULTS: Peak knee flexion was reduced significantly compared with normal heel-toe walking (42.2+/-8.9 degrees toe-walking vs. 59.2+/-5.7 degrees heel-toe walking; P < 0.00001). CONCLUSIONS: This finding, which occurred when controlling for walking speed, may be clinically relevant for patients who have both a toe-walking and a stiff-legged gait pattern. Some of the reduced knee flexion in swing may be merely a consequence of toe-walking, rather than a result of other causes, such as intrinsic spasticity or abnormal muscle firing about the knee.

Adult↗

PubMed1985

Supplemental biotin for swine. I. Influence on feedlot performance, plasma biotin and toe lesions in developing gilts.

Three trials, utilizing a total of 240 crossbred gilts, were conducted to study the influence of 0 (NB) or 220 (SB) microgram supplemental biotin/kg of diet on feedlot performance, plasma biotin and development of toe lesions in developing gilts. Corn-soybean meal diets were fed from weaning to 92 kg body weight. Gilts were housed on expanded-metal floors to 50 kg body weight and on partially slatted concrete floors until completion of the trials. Feedlot performance, hair and structural soundness scores were not different (P greater than .10) between NB and SB gilts. Plasma biotin (PB) levels were elevated (P less than .01) when supplemental biotin was included in the diet. Gilts consuming SB diets had fewer (P less than .01) toe lesions/gilt and lower (P less than .01) toe lesion severity scores/gilt compared with gilts fed NB diets. Heel-horn erosion and heel cracks were the most frequent toe lesions observed. Fewer gilts (P less than .01) developed side-wall toe cracks when fed SB diets. Supplemental biotin reduced the frequency of individual toes containing heel-horn erosion (P less than .10), heel cracks (P less than .05) and side-wall toe cracks (P less than .05) with the severity of these lesions not affected (P greater than .10) by supplemental biotin. These results suggest that biotin levels in corn-soybean meal diets are adequate for feedlot performance, and that supplemental biotin can improve hoof integrity, but will not prevent toe lesions.

Animals↗

PubMedDate not supplied

The kinematic patterns of toe-walkers.

Children who toe-walk can pose a diagnostic problem. The differential diagnosis includes mild spastic diplegia and idiopathic toe-walking. Clinical differentiation between these two patient groups can be particularly difficult, and there are no objective diagnostic tests to assist the clinician. We assessed 50 children who toe-walk to define the kinematic patterns of lower-limb joint motion in the sagittal plane. There were 23 children with mild spastic diplegia. 22 idiopathic toe-walkers, and five normal children who were asked to toe-walk. We found characteristic patterns of knee and ankle motion that differentiated spastic diplegia from idiopathic toe-walking. Normal children asked to toe-walk had the same pattern as the idiopathic group. Gait analysis is a diagnostic tool that enables the clinician objectively to differentiate mild spastic diplegia from idiopathic toe-walking.

Adolescent↗

PubMed1997

Abnormal limb regeneration in the short-toes mutant of the axolotl, Ambystoma mexicanum: studies of age, level of amputation, and extracellular matrix.

Limb regeneration in the short-toes axolotl is impaired. Our goal was to characterize the regeneration process in this mutant by histological and immunocytochemical methods. Previous research indicates that age and a defective basement membrane may be instrumental factors in short-toes axolotl regeneration (Del Rio-Tsonis et al. [1992] Proc. Natl. Acad. Sci. U.S.A., 89:5502-5506). The present results show that limb regeneration can occur even in older (1-2-year-old) short-toes axolotls. The process was always significantly delayed, but the time required for complete regeneration varied. Even so, the basement membrane of short-toes regenerates showed no differences in thickness or shape compared with wild-type regenerates. Distally amputated short-toes limbs gave rise to more digits in the regenerate, indicating that regeneration may be somewhat dependent on the level of amputation. Since extracellular matrix (ECM) remodeling occurs extensively during regeneration, we compared the ECM of the short-toes and wild-type regenerates using monoclonal antibodies (mAbs) MT2 and ST1 (Tassava et al. [1996] Wound Rep. Reg., 4:75-81). The short-toes regenerates showed decreased reactivity to mAb MT2, which identifies type XII collagen, an ECM protein that is normally unregulated during regeneration, and increased reactivity to mAb ST1, which identifies a limb ECM component that typically undergoes breakdown in the distal stump. Thus, impaired regeneration in the short-toes axolotl is correlated with impaired ECM remodeling in the distal limb stump. This supports the view that ECM remodeling plays an important role in regeneration.

Aging↗

PubMed1992

The undulating toe flexion sign in brain death.

Brain-dead patients may exhibit gross spontaneous and reflex movements (e.g., Babinski sign, stereotypic flexion of one or more limbs, and Lazarus sign). We report three brain-dead patients who had unusual complex sequential movements of the toes. Undulating toe flexion was elicited by noxious stimuli to the lower extremities, and consisted of initial plantar flexion of the great toe, followed by sequential brief plantar flexion of the second, third, fourth, and fifth toes. The undulating toe flexion sign differs from previously described responses characterized by plantar flexion of the toes (e.g., Rosselimo's sign and the Mendel-Bechterew sign) in that it consists of complex patterned sequential movements of the digits rather than brief simultaneous flexion and/or fanning of the toes. Neurologists should be aware of this unusual finding, which should not preclude the diagnosis of brain death.

Adult↗

PubMed2002

Relative lengths of fingers and toes in human males and females.

Digital scans of the hands and feet were obtained from 62 heterosexual females and 60 heterosexual males. Scans only of the hands were obtained from 29 homosexual females and 35 homosexual males. The lengths of the individual fingers and toes were estimated from those images by two experienced judges, and length ratios were constructed for all possible pairs of fingers (or toes) on each hand (or foot). Thumbs were not measured, but the great toe was measured and used to construct length ratios. Past research had concentrated on the relative lengths of the index and ring fingers (the 2D:4D ratio). This ratio is close to 1.0 in females and smaller than 1.0 in males. Here 2D:4D did exhibit the largest sex difference, for both hands, followed by 2D:5D and 3D:4D. The sex differences were larger for the right hand than for the left. For both homosexual females and homosexual males, nearly all of the length ratios for fingers were intermediate to those for heterosexual females and heterosexual males; that is, the ratios of homosexual females were masculinized and those of homosexual males were hypomasculinized, but few of these differences were significant. Because many toes were substantially arched, acceptable estimates of length often could not be obtained from the two-dimensional scans, meaning that conclusions about toes are much less certain than those for fingers. Nevertheless, the length ratios were generally larger for toes than for fingers, and the sex differences were generally smaller for toes.

Adult↗

PubMedDate not supplied

Reconstruction of the thumb and digit by toe to hand transplantation.

Since the rapid development of microsurgery it is feasible to replant most severed thumbs and digits. In certain patients, however, the trauma is so severe that replantation cannot be performed, such as crush or burst injuries where the amputated part is badly smashed or broken into pieces. There are many methods used to reconstruct amputated thumbs or digits. In our hospital reconstruction of the thumb is accomplished by second toe transplantation, nail flap of the great toe transplantation and bone graft, and nail flap of the great toe and skeleton from the second toe transplantation. Reconstruction of fingers is undertaken through second toe transplantation and second and third toe transplantation. After total loss of the hand, double second toe transplant is used for reconstruction.

Adult↗

PubMed2003

Treatment of the toe tourniquet syndrome in infants.

INTRODUCTION: The "toe tourniquet syndrome" is the circumferential strangulation by human hair or fibers of one or more toes in infants, which may induce prolonged ischemic injury and tissue necrosis. Release of the strangulation is mandatory to avoid autoamputation of the digit. We recently encountered several incompletely treated cases and would like to emphasize the effective method of treatment. METHODS: A retrospective analysis of pediatric emergency department records of patients treated for "toe tourniquet syndrome" during 1990 to 2001 was performed. Patients undergo a short, longitudinal, deep incision over the area of strangulation on the dorsal aspect of the toe, until the phalanx bone, which allows the complete section of the constricting fibers to be removed without injury to the anatomical structures of the toe. RESULTS: Twenty-one infants (12 boys and nine girls), aged 0-11 months (average 4.6 months), were treated for tourniquet syndrome of one (15 infants) or two (six patients) toes. In 12 patients (57.1%) the right foot was involved. Eight patients (38.1%) had undergone an attempt in the previous few days to release constriction. No complications were encountered. CONCLUSION: The above-described technique is simple and safe and secures the complete release of the strangulation by removal of all hairs or fibers without injury to the anatomical structures of the toe.

Amputation, Traumatic↗

PubMed2006

Vascularized bone blocks from the toe phalanx to solve complex intercalated defects in the fingers.

PURPOSE: Vascularized bone transplants resist infection and allow rapid healing but keeping small bony segments vascularized, as needed for a finger defect, is a challenge. The purpose of this article is to present a cohort of patients with traumatic intercalated compound bony defects in the fingers that were reconstructed by a vascularized toe phalanx (or part of a phalanx) in a single stage. METHODS: Eight patients were treated with an intercalary vascularized bone graft that included a part of the proximal phalanx (3 patients), most of the middle phalanx (4 patients), or a portion of each phalanx (1 patient) of a second toe (totaling 9 bone blocks). There was an associated soft-tissue defect in each patient, an infection in 6 patients, and cartilage loss in 4 patients. The toes were pedicled on the proper digital artery (6 patients) or a segment of the first dorsal metatarsal artery (2 patients). A mean length of 12 mm of vascularized bone was transferred. The associated skin island varied from a minimum of 2 x 1 cm to a maximum of 5 x 3 cm. Bleeding from all of the bone surfaces was evidenced once the clamps were released. The homolateral digital nerve and the contralateral neurovascular pedicle of the toe were kept in place. The toe defect was treated by soft-tissue arthroplasty or arthrodesis. No toe was amputated. RESULTS: Radiologic bony union was evident at 4 to 6 weeks, except in 1 patient with an acute infection whose distal union failed to unite at 6 weeks because the infection recurred. Finger length loss averaged 3 mm. All patients returned to their preoperative occupation. CONCLUSIONS: In this group of patients the toe phalanx reliably maintained its vascularization, allowing us to solve compound osteocutaneous defects in the fingers in a single stage. Donor site morbidity was minimal.

Adult↗

PubMed2004

The multiple monoblock toe-to-hand transfer in digital reconstruction. a report of ten cases.

Ten hands with multiple traumatic finger amputations or congenital agenesis underwent reconstruction by monoblock transfer of multiple toes. Eight patients underwent monoblock transfer of the great and second toes, one patient received the great toe and the metatarsophalangeal joint from the second toe with the same vascular pedicle, and another patient the great, second and third toes as a block. Only part of the great toe was ever taken, while the second toe was totally or partially taken. The surgical technique and the outcome are detailed in this work, with a mean postoperative follow-up of 6 years.

Adolescent↗

PubMed2005

Toe-to-hand transfers: more than 20 years follow-up of five post-traumatic cases.

In post-traumatic losses of the thumb and fingers, reconstruction can be performed with success using various combinations of toe transfers. In this study, we have presented second toe and combined toe transfers which have been followed up for more than 20 years. Second toe transfer was used in four patients for reconstruction of the thumb. Combined second and third toe transfer was performed in two patients with a metacarpal hand for finger reconstruction. Long-term follow-up results show that patients with toe-to-hand transfers have acceptable adaptation to the reconstructed hand and good hand function. Toe transfer should be individually planned and carefully executed to obtain optimal results and minimal disability in the donor foot.

Adaptation, Physiological↗

PubMed1997

Computer-aided video analysis of vertebrofemoral motion during toe touching in healthy subjects.

OBJECTIVE: Despite widespread use of the toe touch test, the relative contribution from vertebral and hip movements has not been clearly established, largely because of unsatisfactory measurement techniques. This study aimed to reinvestigate the kinematics of toe touching by combining computerized videotape analysis with a new model of reference marker placement. METHOD: Twenty-two subjects were videotaped during active toe touching from upright standing. Computer software was then used to derive the sagittal thoracic, lumbar, and hip angles at .02-sec intervals throughout the movement. RESULTS: Hip flexion was directly proportional to toe touch distance (TTD) (r2 = .71) but not lumbar flexion (r2 = .17) or thoracic (r2 = .20) excursion. On average there was .8 degree of thoracolumbar flexion for every 1 degree of hip flexion; however, there were wide variations between subjects. In 19 of 22 subjects the thoracic spine flexed and extended relatively equal amounts during the test resulting in a small total thoracic excursion of 4.8 degrees flexion in unsuccessful toe touchers and 4.0 degrees extension in successful toe touchers. CONCLUSION: The separate contributions of hip, lumbar, and thoracic mobility to toe touching or any other vertebrofemoral motion can only be accurately determined by a measurement strategy that uses the plane of the pelvis to separate vertebral from hip motion and uses tangents at the limits of the thoracic and lumbar regions to separate lumbar from thoracic motion. Using this model the authors found that TTD is not a reliable indicator of either vertebral or hip mobility.

Adolescent↗