Purpose of the study: Amputation of the thumb is a serious hand injury producing a major functional and aesthetic handicap. In 1980, Foucher proposed a twisted two toes transfer associating elements harvested from the first and second toes on the same pedicle for the reconstruction of an ‘articulated’ thumb with preserved potential for growth.

Material and method: Since 2002, two children aged 10 and 14 years underwent this procedure. The thumb amputation was trans MP for one and at the base of P1 for the second. The transfer associated a sheath of skin from the hallux to wrap around the skeleton of the second toe which was harvested as need to the IP or the MP. The aesthetic, functional (400 point scale), and radiological outcomes were assessed.

Results: Follow-up was 5 years and 2.5 years. The aesthetic result was comparable to wrap-around transfers. Regarding the functional outcome, the overall hand function was scored 86% and 72% of normal, mobility 77% and 72%, and force 75% and 79%. One patient had persistent deficient active flexion of the interphalangeal joint because of flexor adherences. Despite the reconstruction of the “two-joint” thumb, fine movements were difficult. Sensitivity was noted normal: Weber 5 and 8 mm. Healing of the donor site was rapid and the sequelae discrete. The first ray was preserved. Gait was not hindered. In one patient, radiographs showed skeleton growth.

Discussion: Transfer of the second toe provides a potential for growth, but the aspect is less than satisfactory and the functional results often disappointing. There are no indications except for very proximal amputations. Total transfer of the great toe would also provide potential for growth, but the voluminous aspect and the very important sequelae for the foot rule out this option.

Conclusion: For growing children, the twisted two toe transfer for amputations of the metacarpophalangeal region is the only available technique allowing nearly normal reconstruction of the thumb in terms of mobility, force, sensitivity, appearance, and growth. The foot reconstruction is simple, aesthetic and functional. The complexity of the procedure may nevertheless limit is use.

Purpose: Transscaphoretrolunate dislocation is the most frequent perilunate dislocation of the carpus (65% according to Herzberg). Treatment remains controversial. The aim of this work was to analyse functional outcome in a homogeneous series of 15 patients treated by open reduction and fixation.

Material and methods: This retrospective analysis of 15 patients, mean age 34 years was conducted at four years follow-up. Clinical outcome was based on the Cooney clinical scoring chart. Static and dynamic x-rays of the wrist were studied. The dislocations were: type I=9, type IIa=5, type II=1 according to the Alnot classification. The scaphoid fractures were: types III and IV=13, type II=2. A dorsal approach was used for six cases, an anterolateral approach for four and a double approach for five. The carpal tunnel was opened in seven cases. The scaphid fracture was fixed by pins in eleven cases, by screws in four, and associated with a corticocancellous graft in five. The carpus was fixed in seven cases with scapholunate pins, with lunotriquetral pins in seven, and radiolunate pins in three.

Results: Mean score was 70±20% with mean flexion 50±17° and mean extension 54±20°. Grip force was 32/45±11 (Jamar). The thumb-index force was 14±5.1. Pain was negligible in 33% of the patients and was disabling in 17%. Climatic pain was reported by 50% of patients; 75% were able to resume their occupational activities. Radiographically we found osetonecrosis of the lunate (n=1), osteonecrosis of the proximal pole of the scaphoid (n=2), non-union of the scaphoid (n=3), radiocarpal osteoarthritis (n=4), SLAC (n=1) and SNAC (n=2).

Discussion: Our outcomes were slightly less favourable than those reported in the literature concerning joint motion. Conversely, for pain, duration of sick leave, and percentage of occupational reclassing, our results were the same as reported in the literature. The series shows that radiographic outcome was favourable with 13% radiocarpal osteoarthritis (38% for Herzberg in 2002 at 96 months. The stability of the scaphoid osteosynthesis remains the key to success (two nonunions for four single pin fixatons). A new analysis at longer follow-up would be interesting to determine the arthrogenic results.