"Toe transfers outperform replantation after digit amputations: outcomes of 126 toe transfers".

Background: The gold standard after digital amputation is assumed to be replantation of the amputated digit. This study seeks to address - using validated functional outcomes in one of the world's largest series of toe transfers - whether toe transfers can match the function of replanted digits. This study also aimed to identify which physical variables improve functional outcomes after toe transfer.

Methods: 75 patients with 126 toe transfers were enrolled from 2015 to 2023 at Chang Gung Memorial Hospital, Linkou, Taiwan. Comparison group was 52 patients with 96 digit replantations from the FRANCHISE study, treated at the same centre. Primary outcome was Michigan Hand Questionnaire (MHQ). Secondary outcomes were 36-Item Short Form Health Survey (SF-36) and Foot Function Index (FFI).

Results: Toe transfers versus digital replantation: Adjusted means revealed superior MHQ scores for toe transfers (75.7) compared to replantation (55.0) (p<0.001), exceeding MCID estimates. Pairwise comparisons noted that these differences increased with increasing severity of injury stratified by FRANCHISE classification. SF36 scores were superior for toe transfers (55.79) versus replantation (53.22) (p=0.008).Factors influencing functional scores after toe transfer: moving 2 point discrimination, active range of motion, tripod grip, and SF36 contributed significantly to MHQ score (r2 = 0.55, p<0.0001) on multivariable regression.

Conclusions: These findings challenge current global approaches to digital amputation. Here, toe transfers are shown to outperform equivalent digit replantations on validated PROMs. This has profound implications on the emergency provision of replantation, and the incorporation of elective toe transfer surgery into health frameworks.