Microsurgery helps toes do a finger's work

ATLANTA , Georgia (Reuters) -- It is clearly a toe, but the 35-year-old carpenter -- who lost his thumb while using a circular saw -- is using it to pick up a penny and to wield a coffee mug.

In another photograph, a 21-year-old farmer who lost all his fingers in an accident curls three toes into a fist.

Such patients are back at work despite traumatic accidents thanks to microsurgical techniques that allow surgeons to draft toes in to do the work of fingers and thumbs, Dr. Kevin Chung of the University of Michigan in Ann Arbor said on Sunday.

He told reporters that few people knew such a swap of their own body parts was available. Yet, when attached properly, a big or middle toe can function just like a finger or a thumb.

"I have seen, repeatedly, patients who have been told there is nothing a physician can do for them," Chung told a meeting of science writers sponsored by the American Medical Association.

Yet he regularly -- he does not yet have a full count of patients -- takes a patient's big toe or second toe and uses it to replace a thumb.

"Fifty percent of the hand's function comes from the thumb," Chung said in an interview. People who have lost a thumb to an accident or surgery, or even those born without a thumb, can use their hands almost normally if one of their own toes is stitched into its place.

"I have a series of patients who have no fingers. I can make them a new thumb and two new fingers," he added.

Recent patients include a 30-year-old man who lost his thumb to cancer and a 10-year-old child whose thumbs were removed after a bacterial infection. Chung shows photographs of another patient using chopsticks and a third wielding a heavy soft drink bottle -- tasks impossible without a thumb.

"Hand function is essentially comparable to the other, normal hand in terms of grip strength, pinch and activity of daily living tasks ... although aesthetically it doesn't look the same," Chung said.

But interestingly, he said, both the patient, as well as family and friends, soon believe the transferred toe does look like a finger. "They start talking in terms of 'my finger is doing this, my finger is doing that'," Chung said.

The surgery itself is tricky and requires training.

Using a microscope and tiny instruments, Chung stretches tissue covering the nerve, called the epineurium, across the gap between hand and the toe. He attaches epineurium from the two main nerves in the base of the missing finger to the corresponding nerves in the replacement toe.

He also connects blood vessels and two main tendons responsible for flexing and extending the digit. The surgery can take five hours on a "good" day and 12 hours if things go wrong, he said.

"But you have to stay there as long as it takes," Chung said. "What alternative do you have? You took somebody's toe off and you have got to stay through until it is a success."

Instead of using tiny surgical pins, Chung uses what he calls mini-plates to attach the bones of the new "finger" to the bones in the hand. This results in a more robust transplant, he said.

Then the nerves get to work growing together, a process that takes about a month.

"A nerve has the inherent ability, once it has been injured, to find the other end," Chung said. "It is amazing. It says 'I have got to find the other end'."

A lot of help is needed to make sure the tissues grow together properly, and the patient has to be ready to do the work, Chung added. "Not every patient is motivated enough to undergo the vigorous physical therapy process," he said.

Considerable manipulation of the hand and fingers is needed. Patients must undergo the exercises and massaging of the scars four or five times a day.

But if this all is done, almost anyone missing a finger is a candidate for the surgery. And unlike patients who have made headlines with hands transplanted from cadavers, no drugs are needed to prevent the body from rejecting the transplant, because it is the patients' own toe.

The patients all can walk and even run normally with minimal pain, he said. But some have what he calls "tremendous affinity" to their toes.

"I have seen 20-year-old kids who lost fingers and who are ideal candidates but they don't want to lose their toes," Chung said. "I can't believe it."

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