Microsurgical reconstruction of distal digits following mutilating hand injuries: results in 121 patients

The Foot as a Donor Site for Reconstruction in the Hand

The foot contains a unique collection of tissue types that can be used in the reconstruction of the hand. Numerous reconstructive options have been presented, some of which have been adopted, such as modifications to procedures that have been described in the past or even newly developed options for hand reconstruction. It is possible to reconstruct missing fingers and other hand structures using tissues taken from the foot rather than removing healthy tissue from a hand that has already been injured. This makes it possible to avoid having healthy tissue removed from an injured hand.

Management of a mutilated hand: the current trends

Mutilated upper limbs suffer loss of substance of various tissues with loss of prehension. The most important factor in salvage of a mutilated hand is involvement of a senior surgeon at the time of initial assessment and debridement. A regional block given on arrival helps through assessment and investigations in a pain-free state. Infection still remains the important negative determinant to outcome and is prevented by emergent radical debridement and early soft tissue cover. Radical debridement and secure skeletal stabilization must be achieved on day one in all situations. Dermal substitutes and negative pressure wound therapy are increasingly used but have not substituted regular soft tissue cover techniques. Ability to perform secondary procedures and the increased use of the reconstructed hand with time keeps reconstruction a better option than prosthesis fitting. Toe transfers and free functioning muscle transfers are the two major secondary procedures that have influenced outcomes.

A flap based on the plantar digital artery arch branch to improve appearance of reconstructed fingers: Anatomical and clinical application

AIM

To investigate blood supply features of the flap based on the plantar digital artery arch and arch branch artery, and the treatment of outcomes of reconstructed fingers by the plantar digital artery arch branch island flap.

METHODS

Eight fresh foot specimens were employed with red emulsion infusion and microdissection. The vascular organization was observed in the second toe, such as initiation site, the course, and the number of the plantar digital artery arch branch. There were 15 fingers of 13 patients (8 males and 5 females) with finger defects accompanied by toe transfer, using the plantar digital artery arch branch flap inserted in the neck of the second toe to correct the appearance defect caused by a narrow "neck" and a bulbous tip.

RESULTS

The intact plantar digital arches were identified in all specimens. The plantar digital artery arch had 5 branches. The range of external diameter of the arch branch was 0.4-0.6 mm. All the plantar digital artery arch branch island flaps and the reconstructed fingers survived. These cases were conducted with a follow-up period for 3-18 months (average, 9 months). All the plantar digital artery arch branch island flaps and reconstructed fingers demonstrated a satisfactory appearance and favorable sense function. The reconstructed finger-tip characteristic was good, with no obvious scar hyperplasia. The range of flexion and extension of reconstructed fingers was favorable as well.

CONCLUSIONS

The plantar digital artery arch and arch branch artery possess regular vasa vasorum and abundant vascularity. A flap based on the plantar digital artery arch branch is an ideal selection for plastic surgery of reconstructed fingers.

Recent Advances in Immediate Toe-to-Hand Transfer

Toe-to-hand transfer is the last option for definitive reconstruction of the hand when digits have been lost as a result of traumatic amputations, congenital anomalies, or tumor ablation. Immediate toe-to-hand transfer for the treatment of acute hand injuries is defined as an emergency operation performed when replantation is impossible or failed. The aim of this article is to propose the indications, advantages and disadvantages of immediate toe to hand transfer as well as to compare the overall results with elective cases.

Risk factors for reexploration in toe-to-hand transfer: a multivariate analysis of 363 cases

BACKGROUND

Reexploration after toe-to-hand transfer increases the risk of failure. In this study, the authors aimed to identify risk factors for reexploration after toe-to-hand transfer.

METHODS

The medical records of 363 patients who underwent single toe-to-hand transfer between 2000 and 2010 were reviewed retrospectively. Patient demographics, clinical data, and operative data were collected, and multivariate analysis was performed.

RESULTS

Of these 363 patients, 299 toes (82.4 percent) had primary success in transplantation. Sixty-four toes required reexploration, of which seven toes failed. The overall success rate was 98.1 percent. Of the 64 toes that required reexploration, arterial spasm was found in 39 (60.9 percent), arterial thrombosis was found in 27 (42.2 percent), and venous thrombosis was found in 16 (25.0 percent). Multivariate logistic regression analysis revealed that postoperative wound infection, metacarpal hand injuries, and preceding flap coverage were independently associated with reexploration.

CONCLUSIONS

Reducing reexploration in toe-to-hand transfer may be facilitated by managing or avoiding these risk factors. Particular attention must be paid to avoid postoperative wound infection, which was the single greatest factor contributing to reexploration (adjusted OR, 12.6).

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Great toe transplant versus thumb replant for isolated thumb amputation: critical analysis of functional outcome

BACKGROUND

Thumb replantation following thumb amputation is the standard of care. When replantation is impossible, microneurovascular great toe transplantation is a well-established option.

METHODS

A retrospective review was conducted to evaluate functional outcome following isolated thumb replantation or great toe transplantation for thumb reconstruction. From 1974 to 1993, 384 thumb amputations were treated and 110 great toe-to-thumb transplantations were performed.

RESULTS

Ninety-one patients with isolated thumb amputation had an 85% survival rate. Failed replants usually resulted from crushing or avulsing injuries. Function of replanted thumbs was better in sharp compared with crush/avulsion injuries. Forty-three isolated thumb reconstructions had a 93% success rate. Function was comparable with thumb replants from sharp injuries. Interphalangeal motion was significantly better in great toe transplants than in replanted thumbs of the crush/avulsion type.

CONCLUSIONS

Amputated thumbs should be replanted. When replantation is not possible or unsuccessful, a transplanted great toe functions as well as, or better than, a replanted thumb.

Posttraumatic finger reconstruction with microsurgical transplantation of toes

This article outlines current methods of toe transplantation as applied to posttraumatic finger reconstruction (excluding the thumb). Key points that are important during the initial assessment and surgical treatment of such injuries are addressed. Reconstructive options for distal and proximal finger injuries, single and multiple finger injuries, and metacarpal hand injuries are presented, and the timing of toe transplantation procedures is discussed. Finally, additional concepts and techniques that, with experience, have proved useful for optimizing functional and esthetic results are highlighted, along with schemes for motor and sensory rehabilitation.

Principles for the management of toe-to-hand transfer in reexploration: toe salvage with a tubed groin flap in the last step

Failure of the transferred toe in toe-to-hand transplantations is a catastrophe and a devastating complication for both the patient and the reconstructive surgeon, as in all microvascular tissue transfers. Management of the toe transfer in the case of reexploration is still a challenging issue, even for experienced microsurgeons. In this report, basic principles for a successful outcome are proposed, based on experience with more than 500 toe-to-hand transfers. Although the requirements for each case may vary, technical details and some basic salvage strategies receive special emphasis. When faced with a problem, the first step should be focused on perceiving the problem differently from under completely normal conditions. The problem may occur at any stage of the procedure. The basic orientations are focused on vasospasm, a thrombus inside the lumen, possible intimal damage that may be caused during the surgery or by a thrombus, or technical failures regarding anastomoses. After all possible revisional procedures have been carried out, if the proper arterial inflow and/or venous outflow are still not provided, or if the general health status of the patient is no longer suitable for additional lengthy procedures, the tubed groin flap can be used to salvage the transferred toe. Between 1996-2004, eight tubed groin flaps were used to salvage transferred toes in the last step of the revisional procedure, with satisfactory results. In conclusion, close follow-up and prompt reexploration when needed are both essential to salvaging transferred toes. Proper surgical strategies and decision-making in reexploration are highly important factors in achieving a successful outcome. In prolonged and recurrent revisional steps, the creation of a tubed flap by means of a reliable flap is an effective procedure as the last step of the salvage procedure.

Immediate partial great toe transfer for the reconstruction of composite defects of the distal thumb

BACKGROUND

Thumb defects distal to the interphalangeal joint do not cause any disability; therefore, any consideration to reconstruct the thumb is governed by the lifestyle and cultural background of the patient. This study presents the excellent results achieved by immediate partial great toe-to-hand transfer to reconstruct acute composite defects of the distal thumb.

METHODS

Fifty-three patients with amputation or crush injury of the distal thumb who underwent partial great toe-to-hand transfer at the authors' institute over an 11-year period were reviewed. Based on the amputation level of the distal thumb, the authors classified the injuries into three groups. Operative techniques used were osteo-onychocutaneous flap with partial or whole toenail from the great toe and partial great toe transfer with arthrodesis of the interphalangeal joint. Overall results were evaluated in terms of success rate, incidence of emergency reexploration, and number and type of secondary operation. Static two-point discrimination, range of motion, pinch strength, and subjective satisfaction were also evaluated.

RESULTS

The success rate of immediate partial great toe-to-hand transfer was 100 percent. The incidence of inflammation and the reexploration rate were not significantly different from those in previously reported articles. In 35 cases where postoperative follow-up was possible, static two-point discrimination, total active range of motion, and pinch strength were generally excellent and the majority of the patients were satisfied with the final outcome.

CONCLUSION

Immediate reconstruction with partial great toe transfer is an excellent option for reconstruction of composite defects of the distal thumb, not only for aesthetic reasons but also for functional purposes.

A Comparison between Primary and Secondary Toe-to-Hand Transplantation

Although primary toe-to-hand transplantation is performed with increasing frequency, its use is still controversial because of the lack of any comparative studies documenting its safety and efficacy. Between August of 1990 and December of 1993, 175 consecutive toe-to-hand transplantations for crush and avulsion injuries were performed in 122 patients. The average interval between injury and primary reconstruction was 7 days, and the average interval between injury and secondary reconstruction was 10.7 months. Follow-up ranged from 18 to 91 months, with an average follow-up of 58 months. There were 31 primary transplantations and 144 secondary transplantations. The survival rate was 96.8 percent (30 of 31) for primary reconstruction and 96.5 percent (139 of 144) for secondary reconstruction. Intraoperative anastomotic revision was necessary in 3.2 percent (one of 31) of primary transplantations and 7.6 percent (11 of 144) of secondary transplantations. Three primary toe-to-hand transplantations (9.7 percent) and 17 secondary toe-to-hand transplantations (11.8 percent) were re-explored in the postoperative period. Each group had one superficial infection. The infection rate was 6.5 percent and 0.7 percent in the primary and secondary groups, respectively. Other complications included partial skin loss, which occurred in one patient (3.2 percent) in the primary group and six patients (4.2 percent of 144 transplantations) in the secondary group. Secondary procedures to improve function were necessary in six secondary transplantations (4.2 percent) and in none of the primary transplantations. There was no statistical difference between the two groups in terms of survival, intraoperative anastomotic revision, re-exploration, future secondary procedure, infection, and complications. This series demonstrates that primary toe-to-hand transplantation can be performed in the suitable candidate safely with as much success as secondary reconstruction. Primary toe transplantation can potentially reduce the overall period of recovery and rehabilitation, allowing the patient to return to work sooner. Further study to evaluate and compare the final functional outcome and return to work time between primary and secondary toe-to-hand transplantation is needed.

Immediate Toe-to-Hand Transfer in Acute Hand Injuries: Overall Results, Compared with Results for Elective Cases

In the past 5 years, 25 mutilated digits were reconstructed with immediate toe-to-hand transfers after acute hand injuries, for 21 patients. The overall results of the immediate toe-to-hand transfers were evaluated and compared with the results of 65 elective procedures performed during the same period by the same surgeon. There were 15 cases of great toe-to-hand transfer for thumb reconstruction, two cases of second toe transfer for index finger reconstruction, and four cases of simultaneous two-toe transfer for reconstruction of multiple-digit amputations. Two cases (two of 25 cases, 8 percent) were successfully salvaged with emergency reexploration. The incidences of emergency reexploration and postoperative infection were not significantly different from those for elective toe-to-hand transfer cases. The duration of industrial insurance coverage was much shorter than for elective cases, averaging 225 days (p < 0.001). Approximately 44 percent of the patients maintained their original jobs after immediate toe-to-hand transfer. The subjective satisfaction self-assessment scores of aesthetic appearance and function for the newly reconstructed thumb averaged 80 and 88 (of a total score of 100), respectively. Although satisfaction was lower than for elective reconstruction (p < 0.001), it was higher than for reconstruction of other digits. The donor-site appearance after great toe harvesting was mostly unsatisfactory. Immediate toe-to-hand transfer provides many advantages over the elective procedure in acute hand injuries, including single-stage reconstruction, shortened convalescence, early return to work, and socioeconomic efficiency. Because there were no significant differences in the success rates, frequencies of complications, or ultimate functional results, immediate toe-to-hand transfer is a safe and reliable procedure that is indicated for specific cases of acute digital amputation.

Minimizing impairment in laborers with finger losses distal to the proximal interphalangeal joint by second toe transfer

Traditionally, toe-to-hand transfers have been reserved for thumb amputations or for use after severe mutilating injuries. The authors report their experience with the use of second toe-for-finger amputations with preserved or reconstructible proximal interphalangeal joints in manual workers. The aim of the procedure was to reduce impairment and to upgrade the hand from a functional and cosmetic standpoint. Fifteen second-toe wrap-around or variations were carried out on 11 adults (18 to 41 years old). Four patients with two or more finger amputations received two sequential second toes; four patients with two finger amputations received one toe; and each of three patients with single-digit amputation received a single toe. All but one amputation were performed less than 3 weeks after the accident. All toes survived. Range of motion at the native proximal interphalangeal joint was more than 90 percent in all patients but one; however, it was minimal at the transplanted joints. Patient satisfaction was high from a cosmetic and functional standpoint. Ten of 11 laborers resumed their previous activity. On the basis of this experience, a classification with aesthetic and functional implications is proposed to help in the decision-making process when dealing with multidigital injuries. It is concluded that second-toe transfer is an excellent choice for finger amputation distal to the proximal interphalangeal joint in laborers. Its prime indication is for amputations of two fingers where at least one toe should be transferred, as required, to achieve an "acceptable hand" (three-fingered hand). Early transfer allows salvage of critical structures from the damaged finger, such as joints, tendons, and bone, that otherwise would be lost. Early transplantation is highly recommended.

Secondary microsurgical reconstruction of nail problems in musicians

Nail reconstruction in musicians is an interesting and challenging undertaking for the surgeon. The second or third toenail is usually selected as a donor nail for fingernail reconstruction, because the size and shape are generally similar. A partial toe transfer from the great toe is preferred for the thumb. Reconstruction of the guitarist's dominant thumb is a typical indication for this rare procedure. The surgeon must bear in mind, however, that the cosmetic aspects cannot be overlooked in a musician who plays before the public. The surgeon, therefore, has to select the best procedure from the various methods available to provide the best functional and aesthetic result.

Outcomes after mutilating hand injuries: review of the literature and recommendations for assessment

The functional outcome of a mutilating hand injury cannot be fully assessed at the time of injury alone. The measure of functional outcome must incorporate the evaluation and severity of the initial injury and the subsequent reconstructive surgeries. The complexity of the hand deserves no less. Restoration of prehensile function is the top priority in reconstruction following mutilating hand injuries, and assessment of outcome should address this goal. Flaps and specialized tissue grafts can restore architecture and balance in the hand. One can reconstruct a thumb and fingers with the big toe and smaller toes to give a functional sensate grip. The assessment of functional outcome should include not only objective measures but also subjective questionnaires that focus on issues most relevant to the patient. The use of questionnaires that have been shown to be valid, reliable, consistent, responsive, and sensitive allows the most meaningful conclusions about and comparisons between treatments. Perhaps because of the unique challenges presented by mutilating hand injuries, a new instrument, specific to mutilating hand injury, may provide the most beneficial information to guide treatment and assess outcome.

Phantom finger phenomena and the effects of toe-to-finger transplantation

Phantom finger phenomena and the effects of toe-to-finger transplantation were studied in 76 patients who had had traumatic finger amputation. Phantom finger phenomena were observed in 48 (63%) patients with the presence of phantom finger only in 30, phantom finger with sensation in nine, and phantom finger with motion also in nine. After toe transplantation, phantom finger phenomena disappeared immediately in about half of the transplanted fingers that had phantom phenomena before toe transplantation, and also in about half of the amputated fingers without the surgery. Conversely, phantom toe phenomena occurred in 13 (17%) patients. Although some patients had mild-to-moderate unpleasant phantom sensations, none had severe or distressing phantom finger pain or phantom toe pain. It is concluded that phantom phenomena occurred in both finger and toe amputations, and that toe-to-finger transplantation appeared to facilitate the disappearance of phantom phenomena not only in the transplanted fingers but also in the amputated but untransplanted fingers. Possible mechanisms for these observations are discussed.

[Qualitative retrospective study comparing 43 advanced-rotated flaps to 19 island type Venkataswami-Subramanian flaps]

OBJECTIVE

In case of a fingertip trauma, the surgeon'aim is to give the finger a good function, that means a fingertip with good sensibility and trophicity. The purpose of this study was to follow-up three different types of flaps used for fingertip reconstruction, and to analyse their sensibility and functional results.

METHOD

62 fingertip-flaps performed in 60 patients were included in this series. Patients were mainly males (45-60), adults (42-60), middle age (mean age = 40), right-handed (55-60) and home-injured (32-60). The dominant side was injured more often (43-60), by section (27-60) or crush (25-60). Patients were reviewed by the same investigator. Various types of flaps were used: 31 Atasoy flaps, 19 neurovascular island unipedicled flaps and 12 Hueston flaps. Sensory results were evaluated using static and moving two-point discrimination tests, and pain and hot-cold discrimination. Esthetic and functional results were also evaluated.

RESULTS

The tactile sensibility was good or excellent in 63% of flaps and the nail looked good in 70% of flaps. Among all flaps, the Atasoy flap obtained the best results.

DISCUSSION

This study showed the good quality of Atasoy and Hueston flaps in fingertip reconstruction. Neurovascular island flaps gave poor results without taking in account the severity of initial trauma.

Toe transplantation for isolated index finger amputations distal to the proximal interphalangeal joint

Functional deficit following single distal index finger amputations has been considered insignificant, and reconstruction is usually not recommended. Herein, 19 cases of second toe transplantation for reconstruction of isolated index finger amputation distal to the proximal interphalangeal joint are presented with long-term functional results. There are 14 men and 5 women. The average age was 26 years. The toe transplantations were performed either as a primary procedure (5 patients) while the wounds were still open or as a secondary procedure (14 patients) after the wounds healed. In 11 patients, the dominant hand was involved. All toes survived completely, although re-exploration was required in three cases (16 percent). The functional evaluation included (1) sensory recovery, where the average static and moving two-point discrimination were 8 mm (range 4 to 15 mm) and 6 mm (range 2 to 15 mm); (2) motor function, where the average of index-thumb pulp-to-pulp pinch compared with the normal hand was 67.5 percent (range 36 to 96 percent); (3) average range of motion in index finger joints (extension/flexion), where metacarpophalangeal joint was 14/90, proximal interphalangeal joint was 0/94, and distal interphalangeal joint was 19/38; and (4) functional and cosmetic results, where percentage of involvement in daily activities and functional capacity of the reconstructed index were 69 percent and 70.5 in average, respectively, over a total score of 100. Average scores of aesthetic appearance and acceptability of donor-site deformity were 74 and 87.5 over a total score of 100, respectively. Toe transplantation for distal index finger amputations improved hand function when performed in selected patients with specific job requirements or high motivation.

Recovery of sympathetic skin responses after digit-to-digit replantation and toe-to-digit transplantation in humans

Sympathetic skin response was utilized to study recovery of sudomotor function in 8 patients who had digit-to-digit replantation and 9 patients who had toe-to-digit transplantation. Sympathetic skin responses evoked by median nerve stimulation or magnetic stimulation of the neck were recorded from the tip of the replanted digits or transplanted toes. The contralateral normal fingers served as controls. The mean intervals between surgery and study were 33 and 37 months, respectively, for digit replantation and toe transplantation. In normal subjects, the sympathetic skin responses recorded from the fingertip were abolished by local anesthesia or cooling of the finger, while those recorded from the palm were not affected. Ischemia of the finger only transiently affected the digit sympathetic skin responses. These data indicate that the digit responses were locally generated and mediated by unmyelinated fibers. After digit replantation, the palm and digit sympathetic skin responses were not different between replanted and normal sides. After toe transplantation, palm sympathetic skin responses were normal, but digit ones had prolonged latency and reduced amplitude. The present findings suggest that recovery of sympathetic sudomotor activity can be nearly complete in digit replantation but less satisfactory in toe transplantation.

Conduction study of digital nerve function recovery following toe-to-digit transplantation and a comparison with digit-to-digit replantation

Recovery of digital nerve function following toe-to-digit transplantation was studied by nerve conduction in 16 patients, and a comparison was made with digit-to-digit replantation in 7 patients. For toe transplantation and digit replantation, the mean interval between injury and surgery was 7 months and 8 h, respectively, while the mean interval between surgery and study was 39 months and 25 months, respectively. Sensory nerve action potentials (NAPs) from digital nerve stimulation were recorded at the wrist and the elbow, whereas mixed NAPs from median nerve stimulation at the wrist were recorded at the elbow. Sensory NAPs from stimulation of the transplanted toe were detectable in 14 patients and showed reduced amplitude, prolonged latency, and slowed conduction velocity. There was retrograde amplitude reduction in the median nerve and in the proximal segment of the digital nerve. Sensory NAPs from the replanted digit were not different from those of the normal digit, nor was a retrograde effect observed. The present data indicate that digital nerve function recovery was incomplete in toe transplantation and nearly complete in digit replantation. The reasons for the differences in recovery following two types of nerve repair are discussed.

Post-operative infection following hand surgery. Guidelines for antibiotic use

An audit was designed to analyse the risk factors for developing post-operative wound infection following hand surgery. 249 consecutive patients were prospectively entered into the study. 236 (95%) patients were available for follow-up. Infection was diagnosed by clinical criteria. There was an infection rate of 10.7% in elective operations and 9.7% in emergency operations. There was no significant reduction in infection rate in the elective group with the use of antibiotics (P = 0.5). In the emergency group of patients peri-operative antibiotic administration was associated with an 8.5-fold reduction in infection rate (P = 0.014). The presence of a dirty wound was associated with a 13.4-fold increase in post-operative wound infection rate (P = 0.002). A postal questionnaire of members of the British Society for Surgery of the Hand revealed a wide variation in antibiotic usage. Guidelines for antibiotic use in patients undergoing hand surgery are presented.

Secondary procedures to improve function after toe-to-hand transfers

From August 1990 to December 1992, 139 toe-to-hand transfers were performed on 99 patients. Crush, avulsion, and combined crush and avulsion were the mechanisms of injury in 92.8% of the cases. Average duration of follow-up was 17 months (1 to 40 months). 133 transfers were successful, an overall survival rate of 95.7%. 19 transfers (14.3%) required secondary procedures for functional improvement. The incidence of secondary procedure on tendon, bone, joint and soft tissue was 9.0%, 1.5%, 2.3% and 3.0% respectively. Flexor tenolysis was the single most common secondary procedure (6.8%). The results of secondary procedures were satisfactory in all but one instance. Transient neurapraxia of an ulnar digital nerve after tenolysis was the only complication of the secondary procedures.

Recovery of sensation and somatosensory evoked potentials following toe-to-digit transplantation in man

Recovery of digital nerve function in 21 patients with toe-to-digit transplantation was evaluated by clinical sensory tests and somatosensory evoked potentials (SEPs) to median and digital nerve stimulation. The mean interval between injury and surgery was 7 months, and that between surgery and study was 31 months. The transplanted toes achieved a satisfactory but incomplete recovery in temperature (warm and cold), pinprick, touch, vibration, and two-point discrimination in that order. The overall sensory status of the transplanted toes appeared to be closer to normal toes than to normal fingers. In SEPs from the transplanted side, median N9, N13, and N20 components had normal latency but reduced amplitude, whereas digital N9 component was usually absent, but N13 and N20 components had prolonged latency and reduced amplitude. Transplantation performed within 1 month after injury prevented amplitude reduction in median SEPs and latency prolongation in digital SEPs. The SEP data suggest that timing of surgery was critical in preventing retrograde effect on the median nerve, and that recovery of digital nerve function was incomplete correlating with clinical sensory findings.

Free snuff-box flap for reconstruction of the wrap-around flap donor site

The big toe donor site of the wrap-around flap has been reconstructed immediately after elevation of the flap with a snuff-box flap from the dorsum of the recipient hand in 6 patients. Rapid wound healing and a satisfactory appearance were achieved.

Single third-toe transfer in hand reconstruction

Eighteen third-toe transfers to the hand were performed from 1984 to 1993 in 15 patients. These patients had multiple amputations, and follow-up ranged from 5 to 78 months with an average of 27 months. Single third-toe-to-hand transfer was elected when (1) the second toe was not available or not suitable for transfer, (2) the second toe was located in the same foot where the great toe had been transferred to the thumb and the second toe was, therefore, spared for gait, or (3) the third toe was a better size match.