Functional and Surgical Outcomes of Second Toe-to-Thumb Microvascular Reconstruction: A Case Series from a Tertiary Care Hospital in Karachi, Pakistan

Functional and Surgical Outcomes of Second Toe-to-Thumb Microvascular Reconstruction: A Case Series from a Tertiary Care Hospital in Karachi, Pakistan | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Functional and Surgical Outcomes of Second Toe-to-Thumb Microvascular Reconstruction: A Case Series from a Tertiary Care Hospital in Karachi, Pakistan Aimen Qavi, Rabia Anwar, Obaid ur Rahman, Muhammad Osama Siddiqui This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7768763/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Traumatic thumb amputations significantly impact daily living and quality of life, and effective reconstructive solutions are needed. This case series evaluated the functional and surgical outcomes of second toe-to-thumb microvascular reconstruction in patients with traumatic thumb amputations, performed at a tertiary care hospital in Karachi, Pakistan. Materials and methods Between 2018 and 2023, five patients underwent second toe-to-thumb transfer, and outcomes were assessed via the Michigan hand outcome questionnaire (MHQ), QuickDASH, and static two-point discrimination. Results All patients achieved satisfactory functional recovery, with QuickDASH scores ranging from 4.5–25 and MHQ scores ranging from 68.3–83.6. Sensory recovery, measured by two-point discrimination ranged from 8 to 10 mm. The study highlights the viability of second toe-to-thumb as a reliable reconstructive option, even in resource limited settings. Moreover, these findings emphasize the importance of early intervention, as patients with shorter delays between injury and reconstruction have better outcomes. Conclusion This case series contributes to the global literature by providing region-specific evidence for thumb reconstruction and underscores the feasibility of complex microvascular procedures in challenging healthcare environments. Toe-to-thumb transfer Microvascular Traumatic thumb amputation Resource-limited setting Figures Figure 1 Figure 2 Figure 3 INTRODUCTION Traumatic thumb amputation is a debilitating incident, with a significant impact on activities of daily living (ADLs) and overall quality of life. Reconstructive approaches for amputated thumb include distraction lengthening of the residual segment, pollicization, osteoplastic reconstruction, and toe transfer. Microvascular toe-to-thumb transfer, first described by Cobbett in 1969 following Buncke’s pioneering work, has since become a well-established practice in modern reconstructive surgery. ( 1 , 2 ) The four surgical techniques used are: great toe transfer, second toe transfer, wrap-around transfer, and trimmed great toe transfer, each of which results in distinct surgical outcomes. ( 1 , 3 , 4 , 5 ) Surgeons’ preferences and interpretations of cosmetic and functional priorities further influence the choice of reconstructive procedure. ( 7 ) Despite advances in microsurgery, traumatic thumb amputation remains the principal indication for toe-to-thumb transfer, with the literature favouring this procedure in cases where the metacarpophalangeal joint is preserved ( 6 ). Reported success rates now exceed 90% in most large series. ( 8 – 11 ) However, outcome measurements among hand surgeons have evolved to consider functional recovery and postoperative quality of life as important indicators of success. ( 12 ) Patient-reported questionnaires include the Michigan Hand Outcomes Questionnaire (MHQ) and the Disabilities of the Arm, Shoulder, and Hand (DASH). The MHQ measures overall hand function, activities of daily living, pain, work performance, aesthetics, and patient satisfaction, whereas the DASH score determines the clinical presentation and strength of the ability to execute complex movements involving the upper extremities. ( 13 ). Second-toe transfer is now a well-established practice for thumb reconstruction, and most reports describe its use in distal or mid-level amputations, with limited literature addressing high-level injuries at or near the carpometacarpal (CMC) joint. To the best of the authors’ knowledge, such reconstructions have not been systematically reported from Pakistan, a resource-limited setting where patients often bear significant out-of-pocket expenses for advanced microsurgical procedures. By presenting this case series, the surgeons aim to highlight the feasibility and functional outcomes of second-toe transfer for CMC-level traumatic thumb amputations and to contribute region-specific evidence to the global reconstructive literature. MATERIALS AND METHODS This single-center case series was conducted at Liaquat National Hospital, Karachi (Jan 2018–Dec 2023). Data for all patients were collected from the hospital’s electronic medical record system and a structured proforma designed specifically for this study (see Supplementary file 1). Ethical approval was obtained (ERC no. 1021-2024-LNH-ERC), and informed consent was secured. Patients with traumatic thumb amputations who underwent free toe-to-thumb transfer with ≥ 6 months of follow-up were included; congenital and postoncologic cases were excluded. All surgeries were performed by a single surgeon under general anaesthesia. Standard preoperative evaluation was performed; postoperative care included flap monitoring, splinting, Kirschner wire removal at 6–8 weeks, and rehabilitation. Outcomes were assessed with the Michigan hand outcomes questionnaire (MHQ), QuickDASH, and static two-point discrimination. Patient demographics, and surgical details are summarized in Table. 1. Table 1 Demographic and clinical characteristics of patients undergoing second toe-to-thumb transfer. SEX AGE MECHAINSM OF INJURY HAND LEVEL DONOR TOE DOMINANT ARTERY COMPLICATIONS M 16 RTA RIGHT CMC SECOND DORSAL NONE M 28 BLAST INJURY RIGHT CMC SECOND DORSAL NONE M 18 MACHINE CRUSH LEFT MCP SECOND PLANTAR NONE M 22 MACHINE CUT INJURY RIGHT CMC SECOND DORSAL NONE M 25 RTA LEFT MCP SECOND DORSAL NONE CASE SERIES CASE 1 A 16-year-old right-hand-dominant school-going boy sustained a road traffic accident resulting in a right-hand degloving injury. On examination, the right hand demonstrated degloving extending from the distal wrist crease to the proximal metacarpophalangeal joint level, with complete palmar and dorsal skin loss except for a small dorsal bridge. The tendons and musculature were exposed, with segmental loss of the second metacarpal and amputation of the thumb at its base. The left hand experienced a degloving injury with amputation of the index finger and extensive palmar skin loss involving the first web space. The middle and ring fingers were amputated at the distal interphalangeal joint level, whereas the thumb and little finger exhibited pulp tissue loss without bone exposure. Initial management included wound washing and debridement. For the right hand, soft tissue coverage was achieved via an abdominal pedicled flap. The flap was divided after 3 weeks, and the wounds healed satisfactorily. Three months later, a second-toe transfer was performed for thumb reconstruction. Intraoperatively, the dorsal metatarsal artery was identified as the dominant arterial supply, and osteosynthesis between the transferred toe bone and hand was achieved via Kirschner wires (K-wires). Tendon repair and digital nerve coaptation were also performed. The donor and recipient sites healed uneventfully without postoperative complications. (Fig. 1 ) On the left side, initial debridement was performed with fracture fixation of the first, second, and third metacarpals using K-wires. After 4–5 days, once the wound was deemed healthy, soft tissue coverage was achieved via a posterior interosseous flap. Healing was uneventful, and the flap survived completely. At follow-up, the patient demonstrated a two-point discrimination of 8 mm, a QuickDASH score of 4.5, and a Michigan hand outcomes questionnaire (MHQ) score of 83.6, reflecting satisfactory sensory recovery and functional postoperative results as reported by the patient. CASE 2 A 28-year-old male shopkeeper resident in Afghanistan sustained a blast injury. He was initially managed at the hospital in his hometown, after which he was referred to our center for reconstructive microsurgery of the right hand. On examination, the patient demonstrated traumatic amputation of the right index finger with associated scar contracture at the thenar region. He also had a left below-elbow amputation, which was performed at the time of injury management in an effort to salvage the limb. Single-stage thumb reconstruction was performed via free second-toe transfer. Intraoperatively, the first dorsal metatarsal artery of the toe was identified as the dominant vessel and was anastomosed to the radial artery of the hand. Osteosynthesis between the metatarsal of the transferred toe and the hand was achieved via Kirschner wires. Tendon and digital nerve repairs were also performed. Both the donor and recipient sites healed uneventfully, with no postoperative complications. At follow-up, the patient demonstrated a static two-point discrimination of 8 mm. Patient-reported outcome measures included a QuickDASH score of 25, reflecting moderate disability, and a Michigan Hand Outcomes Questionnaire (MHQ) score of 68.3, indicating satisfactory but suboptimal functional recovery, considering that his other limb was amputated and that an attempt to restore thumb function in his one functional upper limb was achieved. (Fig. 2 ) CASE 3 An 18-year-old right-handed mechanic caught his left hand in machinery while at work. He sustained amputation of the left thumb at the metacarpophalangeal joint. He presented initially with an amputation of the thumb after 12 hours. The amputated thumb was not preserved by the patient, as it was crushed via a machine. On examination, the exposed thenar musculature and metacarpal bone were observed. Preliminary wound washing/debridement was carried out using normal saline. Initially, the remaining viable skin flaps were approximated and sutured to provide temporary coverage of the exposed bone and thenar musculature. The patient was managed conservatively with regular dressing until satisfactory wound healing was achieved. He was counselled for toe-to-thumb reconstruction however he returned after six months for reconstructive procedures. Definitive reconstructive surgery was performed, and preoperative markings and necessary investigations were ordered. Second toe transfer was planned, and primary closure was conducted at the donor site. The plantar metatarsal artery was identified as the dominant arterial supply of the harvested toe, and osteosynthesis was performed with K-wires. On the postoperative follow-up, the patient demonstrated two-point discrimination of 10 mm, and the self-reported MHQ and QuickDASH scores were 74.1 and 18.2, respectively. CASE 4 A 22-year-old male presented within 6 hours of a crush avulsion injury to the right thumb, which was sustained in a machine accident. On arrival, the amputated part was examined for the possibility of replantation; however, owing to the avulsion nature of the injury, replantation was deemed infeasible. Clinical examination revealed bruising around the thenar region and degloved skin over the remaining stump. Radiographs confirmed amputation at the carpometacarpal joint level. The skin flaps were preserved for demarcation, and the wound was managed conservatively with close follow-up on an outpatient basis. After satisfactory wound healing, the patient was offered delayed reconstruction with a toe transfer. Second-toe transfer was performed. Preoperatively, markings were placed on the donor site, and the recipient site was explored with removal of residual fibrotic tissue. The second toe was harvested on the dorsal metatarsal artery, which was anastomosed to the radial artery at the wrist. Venous outflow was established via serial coaptation of the dorsal and plantar veins, and digital nerves were coapted to recipient branches to optimize sensory recovery. Osteosynthesis was achieved with a K-wire. The postoperative course was uneventful, with complete flap survival. At follow-up, the patient achieved two-point discrimination of 8 mm, a QuickDASH score of 6.4, and a Michigan hand outcomes questionnaire (MHQ) score of 83.5. CASE 5 A 25-year-old male sustained a left-hand degloving injury following a road traffic accident, resulting in amputations of the thumb and index finger at the metacarpophalangeal joint level. He was initially managed at a peripheral hospital, where no attempt at replantation was made and the amputated parts were not preserved. At presentation to our unit 24 hours later, examination revealed extensive palmar skin degloving with exposed soft tissue and flexor tendons of the index finger. Initial management included debridement of nonviable tissue, index ray amputation with preservation of viable skin flaps for coverage, and terminalization of the thumb stump. The patient was subsequently counselled for delayed thumb reconstruction. Six months later, a second-toe transfer was performed. The donor toe was harvested on the dorsal metatarsal artery, which was confirmed as the dominant vascular pedicle and anastomosed to the radial artery. Venous drainage was established with the dorsal and plantar veins, and digital nerve coaptation was performed for sensory restoration. The postoperative course was uneventful, with complete flap survival and promising wound healing. At the final follow-up, the patient demonstrated a two-point discrimination of 10 mm, a QuickDASH score of 13.6, and an MHQ score of 81.46. Table 2 Functional outcomes following second-toe to thumb transfer. Two-point discrimination QuickDASH score MHQ score 1 8 mm 4.5 83.6 2 8 mm 25 68.3 3 10 mm 18.2 74.1 4 8 mm 6.8 84.35 5 10 mm 13.6 81.46 SURGICAL APPROACH After preoperative marking of the recipient vessels, skin incisions were planned accordingly. The hand was dissected to isolate the extensor and flexor tendon ends, digital nerves, and remnant bone, which were prepared appropriately. Any neuromas encountered were excised to ensure tension-free coaptation. In all cases, the second toe was selected as the donor. Dissection was initiated through a dorsal first web space incision, and the neurovascular structures were identified. Both the dorsal and plantar systems were evaluated; the first dorsal metatarsal artery was dominant in the majority of patients, whereas in one patient, the first plantar metatarsal artery was found to be dominant and traced retrogradely to its origin from the dorsalis pedis artery. The vascular pedicle was harvested along with the accompanying dorsal and plantar veins, dorsal and volar digital nerves, and flexor and extensor hallucis longus tendons. Bone was harvested either with the metatarsophalangeal joint or separated from the metatarsus, depending on the recipient defect. Osteosynthesis was achieved with Kirschner wires in all patients (Fig. 3 ). Reconstruction followed the standard sequence used in replantation surgery: fixation of the bone, repair of the extensor tendon, repair of the flexor tendon, nerve coaptation, arterial anastomosis, venous anastomosis, and finally, skin closure. The extensor hallucis longus tendon was coapted to the residual extensor pollicis longus tendon, and the flexor hallucis longus tendon was similarly attached to the flexor pollicis longus via the Pulvertaft-Weave technique. Vascular anastomoses were performed under the operating microscope, with the donor artery (dorsal or plantar metatarsal) connected in an end-to-side fashion to the radial artery. Standard microsurgical techniques were employed for venous and neural coaptation. DISCUSSION Functional Outcomes Toe-to-thumb transfer remains the gold standard for restoring thumb function after traumatic amputation, particularly in young and active patients. In our series, postoperative outcomes demonstrated two-point discrimination ranging from 8 to 10 mm, QuickDASH scores between 4.5 and 25, and MHQ scores ranging from 68.3 to 83.6. These results are consistent with those reported in the literature. Several authors have shown significant improvements in disability scores after toe transfer. Daryousch et al. reported a mean M2-DASH score of 8.3 following second toe transfer, concluding that this method provided superior functional outcomes compared with index pollicization or osteocutaneous flaps ( 23 ). Similarly, postoperative DASH scores of 25–31 have been documented in unilateral thumb reconstructions using callus distraction. Dewey et al. described improvements in burn-related thumb deformities, with DASH scores decreasing from 78 to 53 following opposition splinting ( 22 ). Our series demonstrated comparable, if not superior, patient-reported outcomes, particularly in patients reconstructed within a shorter time frame from injury. Case 1 and 4 achieved QuickDASH scores less than 10, reflecting near-normal hand function, whereas Case 2, who underwent delayed referral and with concomitant contralateral amputation, reported a higher QuickDASH (25) and lower MHQ (68.3) scores, highlighting the influence of systemic trauma and the timing of reconstruction on functional recovery. Choice of Donor Toe Great toe transfer has historically been considered the most reliable option for providing both length and bulk ( 1 , 15 , 18 ). However, disadvantages include significant donor site morbidity due to disruption of the windlass mechanism ( 17 , 20 ). The second toe transfer, as utilized in our series, provides adequate length with lower donor site morbidity and is often favoured when aesthetics, gait preservation, or cultural concerns preclude great toe harvest. While some studies report inferior grip and pinch strength compared with great toe transfers ( 16 ), our findings confirm that second toe transfer can achieve satisfactory hand function in carefully selected patients. Levels of the Amputation and Reconstruction Strategies The level of thumb amputation strongly influences reconstructive planning. At the carpometacarpal (CMC) level, challenges include restoring both length and web space. Authors such as Sabapathy have advocated staged procedures using groin flaps combined with delayed toe transfers ( 17 ). Others have described combined free tissue flaps ( 19 ). These multistage reconstructions increase morbidity, cost, and operative time. In contrast, our approach of single-stage second toe transfer, even at the CMC level, yielded acceptable functional and sensory outcomes with QuickDASH scores as low as 6.4, supporting the feasibility of this strategy in resource-limited settings. Timing of Reconstruction The use of immediate versus delayed toe transfer continues to be debated. Early reconstruction allows the restoration of length and function before soft tissue contracture sets in, whereas delayed procedures permit staged wound conditioning and optimize recipient vessel availability. In our cohort, patients reconstructed within weeks of injury (Case 1, Case 4) demonstrated superior patient-reported outcomes compared than those underwent delayed procedures after several months (Case 3, Case 5). These findings align with the reports of Adani et al., who reported better sensibility and functional scores in immediate versus delayed transfers ( 24 ). CONCLUSION Second toe-to-thumb transfer remains a reliable and functionally effective option for thumb reconstruction, particularly in cases of proximal amputations where other techniques are limited. Despite the financial burden and technical demands in resource-constrained settings, this series demonstrated favourable sensory and functional outcomes, highlighting its role as a viable reconstructive option in carefully selected patients. Abbreviations MHQ: Michigan Hand Outcomes Questionnaire; DASH: Disabilities of the Arm, Shoulder, and Hand; CMC: carpometacarpal; MCP: metacarpophalangeal; RTA: road traffic accident; mm: millimeter Declarations Ethics approval and consent to participate: This study was conducted in accordance with the ethical standards of Helsinki declaration and its later amendments. Ethical approval was obtained from Liaquat National Hospital Ethical Review Committee (approval no. 1021-2024-LNH-ERC). Written informed consent for participation and publication of identifiable information and images was obtained from all patients. Consent to publish : Written informed consent was obtained from the patients for publication of their clinical details and accompanying images. Availability of data and materials: The raw data supporting the findings of this study are not publicly available due to hospital confidentiality policies and ethical restrictions, as they contain patient medical information. De-identified data may be made available from the corresponding author on reasonable request and with permission from Liaquat National Hospital. Conflict of interest: The authors declare no conflicts of interest Funding: This study did not receive any external funding. Authors’ contributions: A.Q.: Conceptualization, literature review, data collection, data analysis, methodology guidance, manuscript editing; O.S.: literature review, original manuscript draft; R.A.: critical revision of manuscript; O. R.: supervision, reviewing. All authors approved the final version of manuscript. Acknowledgments: not applicable Clinical trial number : not applicable. References Cobbett JR. Free digital transfer. Report of a case of transfer of a great toe to replace an amputated thumb. J Bone Joint Surg Br. 1969;51(4):677–9. Buncke HJ Jr., Buncke CM, Schulz WP. Immediate Nicoladoni procedure in the Rhesus monkey, or hallux-to-hand transplantation, utilising microminiature vascular anastomoses. Br J Plast Surg. 1966;19(4):332–7. Morrison WA, O’Brien BM, MacLeod AM. Thumb reconstruction with a free neurovascular wrap-around flap from the big toe. J Hand Surg. 1980;5(6):575–83. Wei FC, Chen HC, Chuang CC, Chen SH. Microsurgical thumb reconstruction. 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Wei FC, Chen HC, Chuang CC, Noordhoff MS. Reconstruction of the thumb with a wrap-around flap from the big toe. Plast Reconstr Surg. 1988;82(4):556–68. Oña JJ, Rodríguez-Lorenzo A, López-Oliva F, et al. Two free flaps for thumb reconstruction at the carpometacarpal joint level. J Plast Reconstr Aesthetic Surg. 2012;65(9):1185–91. Yajima H, Tamai S, Ono H, et al. Callus distraction lengthening in the reconstruction of amputated thumbs. J Hand Surg. 2002;27(3):521–6. Iba K, Wada T, Aoki M, et al. Distraction lengthening of the thumb metacarpal in posttraumatic thumb amputations. J Hand Surg. 2003;28(5):852–6. Dewey WS, Richard RL, Parry IS. Use of opposition splints in burn-related thumb deformities. J Burn Care Rehabilitation. 2004;25(2):138–42. Krabbe-Timmerman IS, Daryousch I, Azzopardi EA, et al. Outcomes of toe-to-thumb transfer in adults: A systematic review. J Hand Surg Eur Volume. 2016;41(5):492–500. Adani R, Busa R, Castagnetti C, Caroli A. Delayed versus immediate toe-to-hand transfer in traumatic amputations. Microsurgery. 2003;23(1):35–9. Additional Declarations No competing interests reported. Supplementary Files Supplementaryfile1.datacollectionproforma.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7768763","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":549377477,"identity":"3ddd115d-2aa9-4e37-a451-394d0d2b7da8","order_by":0,"name":"Aimen 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10:00:52","extension":"tiff","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":2051998,"visible":true,"origin":"","legend":"","description":"","filename":"Figure3.tiff","url":"https://assets-eu.researchsquare.com/files/rs-7768763/v1/160e8f9576d73388c6d6dfc2.tiff"},{"id":96617407,"identity":"95d9ccf9-0e74-4e72-99b2-9912ef4f0018","added_by":"auto","created_at":"2025-11-24 10:27:07","extension":"tif","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":9437376,"visible":true,"origin":"","legend":"","description":"","filename":"Figure11.tif","url":"https://assets-eu.researchsquare.com/files/rs-7768763/v1/917677afcef1f23cd74840b4.tif"},{"id":96617403,"identity":"eec60491-ab5d-45ab-84d4-8c593fe82c8a","added_by":"auto","created_at":"2025-11-24 10:27:06","extension":"png","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":572953,"visible":true,"origin":"","legend":"","description":"","filename":"OnlineFigure2.png","url":"https://assets-eu.researchsquare.com/files/rs-7768763/v1/7ef4a530438c935d07e6a6a6.png"},{"id":96708458,"identity":"de2c91fb-0d45-4dd1-8c34-222e44e36bcf","added_by":"auto","created_at":"2025-11-25 10:03:06","extension":"png","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":1839949,"visible":true,"origin":"","legend":"","description":"","filename":"OnlineFigure3.png","url":"https://assets-eu.researchsquare.com/files/rs-7768763/v1/84c81719829643f1a6481f9d.png"},{"id":96617399,"identity":"4f2866b3-ab35-4a13-b7cb-307bb66e32de","added_by":"auto","created_at":"2025-11-24 10:27:06","extension":"png","order_by":14,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":563955,"visible":true,"origin":"","legend":"","description":"","filename":"OnlineFigure11.png","url":"https://assets-eu.researchsquare.com/files/rs-7768763/v1/87155b1c76faa0cf501df961.png"},{"id":96617406,"identity":"fa43faa3-63c7-42fa-b204-f1e01d8987f0","added_by":"auto","created_at":"2025-11-24 10:27:06","extension":"xml","order_by":15,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":71515,"visible":true,"origin":"","legend":"","description":"","filename":"9fa642064f1a41b299439ed9498fb6711structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7768763/v1/409f9d023ba0245c7e6076ae.xml"},{"id":96708261,"identity":"efcbd420-d414-499d-93dd-7898e9bec36d","added_by":"auto","created_at":"2025-11-25 09:59:54","extension":"html","order_by":16,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":77881,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7768763/v1/37724c21f9a299592f53cb85.html"},{"id":96708321,"identity":"f96ae5a5-fc7f-43ba-88f3-0fd37d3a1ce6","added_by":"auto","created_at":"2025-11-25 10:01:05","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":11476911,"visible":true,"origin":"","legend":"\u003cp\u003eInitial presentation of a degloved hand (A). Hand coverage with abdominal flap (B). Toe harvest and anastomosis shown (C–D).\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7768763/v1/c9d121f330d4365702c72bc8.png"},{"id":96708753,"identity":"a0f337ab-5542-40b1-9e66-5e65672da98c","added_by":"auto","created_at":"2025-11-25 10:05:20","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":11578876,"visible":true,"origin":"","legend":"\u003cp\u003eInitial presentation of hand (A), and donor foot marking shown (B). Recipient site preparation showing artery and vein (yellow loops), nerves (blue loops) and tendons (FPL,EPL) (C). Donor toe harvest with its neurovascular structures and tendons (D). Immediate post-operative result (E-F). Right functional hand with toe transfer with contralateral amputated limb (G).\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-7768763/v1/701b901b04fb887e5e039425.png"},{"id":96708269,"identity":"881d3f1b-87fc-4c6b-915a-05f4efd7e08d","added_by":"auto","created_at":"2025-11-25 09:59:57","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":5290041,"visible":true,"origin":"","legend":"\u003cp\u003eRadiological presentation of osteosynthesis.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-7768763/v1/c0cf6fcc95a7a1a5b80b3960.png"},{"id":108183265,"identity":"f5005637-3814-442e-8d3b-32fadc0d1272","added_by":"auto","created_at":"2026-04-30 09:00:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":26742048,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7768763/v1/ec011c0e-4e8c-4c9b-88f1-ebe7432e58c3.pdf"},{"id":96617388,"identity":"cf0bc84c-39ec-4939-8577-9abd9beb03ee","added_by":"auto","created_at":"2025-11-24 10:27:06","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":26939,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile1.datacollectionproforma.docx","url":"https://assets-eu.researchsquare.com/files/rs-7768763/v1/9b3c0b586b6a411c8e08aeda.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Functional and Surgical Outcomes of Second Toe-to-Thumb Microvascular Reconstruction: A Case Series from a Tertiary Care Hospital in Karachi, Pakistan","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eTraumatic thumb amputation is a debilitating incident, with a significant impact on activities of daily living (ADLs) and overall quality of life. Reconstructive approaches for amputated thumb include distraction lengthening of the residual segment, pollicization, osteoplastic reconstruction, and toe transfer. Microvascular toe-to-thumb transfer, first described by Cobbett in 1969 following Buncke\u0026rsquo;s pioneering work, has since become a well-established practice in modern reconstructive surgery. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) The four surgical techniques used are: great toe transfer, second toe transfer, wrap-around transfer, and trimmed great toe transfer, each of which results in distinct surgical outcomes. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eSurgeons\u0026rsquo; preferences and interpretations of cosmetic and functional priorities further influence the choice of reconstructive procedure. (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) Despite advances in microsurgery, traumatic thumb amputation remains the principal indication for toe-to-thumb transfer, with the literature favouring this procedure in cases where the metacarpophalangeal joint is preserved (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Reported success rates now exceed 90% in most large series. (\u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eHowever, outcome measurements among hand surgeons have evolved to consider functional recovery and postoperative quality of life as important indicators of success. (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) Patient-reported questionnaires include the Michigan Hand Outcomes Questionnaire (MHQ) and the Disabilities of the Arm, Shoulder, and Hand (DASH). The MHQ measures overall hand function, activities of daily living, pain, work performance, aesthetics, and patient satisfaction, whereas the DASH score determines the clinical presentation and strength of the ability to execute complex movements involving the upper extremities. (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSecond-toe transfer is now a well-established practice for thumb reconstruction, and most reports describe its use in distal or mid-level amputations, with limited literature addressing high-level injuries at or near the carpometacarpal (CMC) joint. To the best of the authors\u0026rsquo; knowledge, such reconstructions have not been systematically reported from Pakistan, a resource-limited setting where patients often bear significant out-of-pocket expenses for advanced microsurgical procedures. By presenting this case series, the surgeons aim to highlight the feasibility and functional outcomes of second-toe transfer for CMC-level traumatic thumb amputations and to contribute region-specific evidence to the global reconstructive literature.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003eThis single-center case series was conducted at Liaquat National Hospital, Karachi (Jan 2018–Dec 2023). Data for all patients were collected from the hospital’s electronic medical record system and a structured proforma designed specifically for this study (see Supplementary file 1). Ethical approval was obtained (ERC no. 1021-2024-LNH-ERC), and informed consent was secured. Patients with traumatic thumb amputations who underwent free toe-to-thumb transfer with ≥ 6 months of follow-up were included; congenital and postoncologic cases were excluded.\u003c/p\u003e\u003cp\u003eAll surgeries were performed by a single surgeon under general anaesthesia. Standard preoperative evaluation was performed; postoperative care included flap monitoring, splinting, Kirschner wire removal at 6–8 weeks, and rehabilitation.\u003c/p\u003e\u003cp\u003eOutcomes were assessed with the Michigan hand outcomes questionnaire (MHQ), QuickDASH, and static two-point discrimination.\u003c/p\u003e\u003cp\u003ePatient demographics, and surgical details are summarized in Table. 1.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographic and clinical characteristics of patients undergoing second toe-to-thumb transfer.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSEX\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAGE\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMECHAINSM OF INJURY\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHAND\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eLEVEL\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eDONOR TOE\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eDOMINANT ARTERY\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eCOMPLICATIONS\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRTA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRIGHT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eCMC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eSECOND\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eDORSAL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eNONE\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBLAST INJURY\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRIGHT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eCMC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eSECOND\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eDORSAL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eNONE\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMACHINE CRUSH\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLEFT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMCP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eSECOND\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003ePLANTAR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eNONE\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMACHINE CUT INJURY\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRIGHT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eCMC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eSECOND\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eDORSAL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eNONE\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRTA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLEFT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMCP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eSECOND\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eDORSAL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eNONE\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003cdiv id=\"Sec4\" class=\"Section3\"\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"CASE SERIES","content":"\u003ch2\u003eCASE 1\u003c/h2\u003e\u003cp\u003eA 16-year-old right-hand-dominant school-going boy sustained a road traffic accident resulting in a right-hand degloving injury. On examination, the right hand demonstrated degloving extending from the distal wrist crease to the proximal metacarpophalangeal joint level, with complete palmar and dorsal skin loss except for a small dorsal bridge. The tendons and musculature were exposed, with segmental loss of the second metacarpal and amputation of the thumb at its base. The left hand experienced a degloving injury with amputation of the index finger and extensive palmar skin loss involving the first web space. The middle and ring fingers were amputated at the distal interphalangeal joint level, whereas the thumb and little finger exhibited pulp tissue loss without bone exposure.\u003c/p\u003e\u003cp\u003eInitial management included wound washing and debridement. For the right hand, soft tissue coverage was achieved via an abdominal pedicled flap. The flap was divided after 3 weeks, and the wounds healed satisfactorily. Three months later, a second-toe transfer was performed for thumb reconstruction. Intraoperatively, the dorsal metatarsal artery was identified as the dominant arterial supply, and osteosynthesis between the transferred toe bone and hand was achieved via Kirschner wires (K-wires). Tendon repair and digital nerve coaptation were also performed. The donor and recipient sites healed uneventfully without postoperative complications. (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eOn the left side, initial debridement was performed with fracture fixation of the first, second, and third metacarpals using K-wires. After 4–5 days, once the wound was deemed healthy, soft tissue coverage was achieved via a posterior interosseous flap. Healing was uneventful, and the flap survived completely.\u003c/p\u003e\u003cp\u003eAt follow-up, the patient demonstrated a two-point discrimination of 8 mm, a QuickDASH score of 4.5, and a Michigan hand outcomes questionnaire (MHQ) score of 83.6, reflecting satisfactory sensory recovery and functional postoperative results as reported by the patient.\u003c/p\u003e\n\u003ch3\u003eCASE 2\u003c/h3\u003e\n\u003cp\u003eA 28-year-old male shopkeeper resident in Afghanistan sustained a blast injury. He was initially managed at the hospital in his hometown, after which he was referred to our center for reconstructive microsurgery of the right hand. On examination, the patient demonstrated traumatic amputation of the right index finger with associated scar contracture at the thenar region. He also had a left below-elbow amputation, which was performed at the time of injury management in an effort to salvage the limb.\u003c/p\u003e\u003cp\u003eSingle-stage thumb reconstruction was performed via free second-toe transfer. Intraoperatively, the first dorsal metatarsal artery of the toe was identified as the dominant vessel and was anastomosed to the radial artery of the hand. Osteosynthesis between the metatarsal of the transferred toe and the hand was achieved via Kirschner wires. Tendon and digital nerve repairs were also performed. Both the donor and recipient sites healed uneventfully, with no postoperative complications. At follow-up, the patient demonstrated a static two-point discrimination of 8 mm. Patient-reported outcome measures included a QuickDASH score of 25, reflecting moderate disability, and a Michigan Hand Outcomes Questionnaire (MHQ) score of 68.3, indicating satisfactory but suboptimal functional recovery, considering that his other limb was amputated and that an attempt to restore thumb function in his one functional upper limb was achieved. (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\n\u003ch3\u003eCASE 3\u003c/h3\u003e\n\u003cp\u003eAn 18-year-old right-handed mechanic caught his left hand in machinery while at work. He sustained amputation of the left thumb at the metacarpophalangeal joint. He presented initially with an amputation of the thumb after 12 hours. The amputated thumb was not preserved by the patient, as it was crushed via a machine.\u003c/p\u003e\u003cp\u003eOn examination, the exposed thenar musculature and metacarpal bone were observed. Preliminary wound washing/debridement was carried out using normal saline. Initially, the remaining viable skin flaps were approximated and sutured to provide temporary coverage of the exposed bone and thenar musculature. The patient was managed conservatively with regular dressing until satisfactory wound healing was achieved. He was counselled for toe-to-thumb reconstruction however he returned after six months for reconstructive procedures.\u003c/p\u003e\u003cp\u003eDefinitive reconstructive surgery was performed, and preoperative markings and necessary investigations were ordered. Second toe transfer was planned, and primary closure was conducted at the donor site. The plantar metatarsal artery was identified as the dominant arterial supply of the harvested toe, and osteosynthesis was performed with K-wires.\u003c/p\u003e\u003cp\u003eOn the postoperative follow-up, the patient demonstrated two-point discrimination of 10 mm, and the self-reported MHQ and QuickDASH scores were 74.1 and 18.2, respectively.\u003c/p\u003e\n\u003ch3\u003eCASE 4\u003c/h3\u003e\n\u003cp\u003eA 22-year-old male presented within 6 hours of a crush avulsion injury to the right thumb, which was sustained in a machine accident. On arrival, the amputated part was examined for the possibility of replantation; however, owing to the avulsion nature of the injury, replantation was deemed infeasible. Clinical examination revealed bruising around the thenar region and degloved skin over the remaining stump. Radiographs confirmed amputation at the carpometacarpal joint level. The skin flaps were preserved for demarcation, and the wound was managed conservatively with close follow-up on an outpatient basis. After satisfactory wound healing, the patient was offered delayed reconstruction with a toe transfer.\u003c/p\u003e\u003cp\u003eSecond-toe transfer was performed. Preoperatively, markings were placed on the donor site, and the recipient site was explored with removal of residual fibrotic tissue. The second toe was harvested on the dorsal metatarsal artery, which was anastomosed to the radial artery at the wrist. Venous outflow was established via serial coaptation of the dorsal and plantar veins, and digital nerves were coapted to recipient branches to optimize sensory recovery. Osteosynthesis was achieved with a K-wire.\u003c/p\u003e\u003cp\u003eThe postoperative course was uneventful, with complete flap survival. At follow-up, the patient achieved two-point discrimination of 8 mm, a QuickDASH score of 6.4, and a Michigan hand outcomes questionnaire (MHQ) score of 83.5.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eCASE 5\u003c/h2\u003e\u003cp\u003eA 25-year-old male sustained a left-hand degloving injury following a road traffic accident, resulting in amputations of the thumb and index finger at the metacarpophalangeal joint level. He was initially managed at a peripheral hospital, where no attempt at replantation was made and the amputated parts were not preserved. At presentation to our unit 24 hours later, examination revealed extensive palmar skin degloving with exposed soft tissue and flexor tendons of the index finger. Initial management included debridement of nonviable tissue, index ray amputation with preservation of viable skin flaps for coverage, and terminalization of the thumb stump. The patient was subsequently counselled for delayed thumb reconstruction. Six months later, a second-toe transfer was performed. The donor toe was harvested on the dorsal metatarsal artery, which was confirmed as the dominant vascular pedicle and anastomosed to the radial artery. Venous drainage was established with the dorsal and plantar veins, and digital nerve coaptation was performed for sensory restoration. The postoperative course was uneventful, with complete flap survival and promising wound healing. At the final follow-up, the patient demonstrated a two-point discrimination of 10 mm, a QuickDASH score of 13.6, and an MHQ score of 81.46.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eFunctional outcomes following second-toe to thumb transfer.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTwo-point discrimination\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQuickDASH score\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMHQ score\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 mm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e83.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 mm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e68.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 mm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e74.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 mm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e84.35\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 mm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e81.46\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSURGICAL APPROACH\u003c/h3\u003e\n\u003cp\u003eAfter preoperative marking of the recipient vessels, skin incisions were planned accordingly. The hand was dissected to isolate the extensor and flexor tendon ends, digital nerves, and remnant bone, which were prepared appropriately. Any neuromas encountered were excised to ensure tension-free coaptation.\u003c/p\u003e\u003cp\u003eIn all cases, the second toe was selected as the donor. Dissection was initiated through a dorsal first web space incision, and the neurovascular structures were identified. Both the dorsal and plantar systems were evaluated; the first dorsal metatarsal artery was dominant in the majority of patients, whereas in one patient, the first plantar metatarsal artery was found to be dominant and traced retrogradely to its origin from the dorsalis pedis artery. The vascular pedicle was harvested along with the accompanying dorsal and plantar veins, dorsal and volar digital nerves, and flexor and extensor hallucis longus tendons.\u003c/p\u003e\u003cp\u003eBone was harvested either with the metatarsophalangeal joint or separated from the metatarsus, depending on the recipient defect. Osteosynthesis was achieved with Kirschner wires in all patients (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Reconstruction followed the standard sequence used in replantation surgery: fixation of the bone, repair of the extensor tendon, repair of the flexor tendon, nerve coaptation, arterial anastomosis, venous anastomosis, and finally, skin closure. The extensor hallucis longus tendon was coapted to the residual extensor pollicis longus tendon, and the flexor hallucis longus tendon was similarly attached to the flexor pollicis longus via the Pulvertaft-Weave technique. Vascular anastomoses were performed under the operating microscope, with the donor artery (dorsal or plantar metatarsal) connected in an end-to-side fashion to the radial artery. Standard microsurgical techniques were employed for venous and neural coaptation.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eFunctional Outcomes\u003c/h2\u003e\u003cp\u003eToe-to-thumb transfer remains the gold standard for restoring thumb function after traumatic amputation, particularly in young and active patients. In our series, postoperative outcomes demonstrated two-point discrimination ranging from 8 to 10 mm, QuickDASH scores between 4.5 and 25, and MHQ scores ranging from 68.3 to 83.6. These results are consistent with those reported in the literature.\u003c/p\u003e\u003cp\u003eSeveral authors have shown significant improvements in disability scores after toe transfer. Daryousch et al. reported a mean M2-DASH score of 8.3 following second toe transfer, concluding that this method provided superior functional outcomes compared with index pollicization or osteocutaneous flaps (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Similarly, postoperative DASH scores of 25\u0026ndash;31 have been documented in unilateral thumb reconstructions using callus distraction. Dewey et al. described improvements in burn-related thumb deformities, with DASH scores decreasing from 78 to 53 following opposition splinting (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOur series demonstrated comparable, if not superior, patient-reported outcomes, particularly in patients reconstructed within a shorter time frame from injury. Case 1 and 4 achieved QuickDASH scores less than 10, reflecting near-normal hand function, whereas Case 2, who underwent delayed referral and with concomitant contralateral amputation, reported a higher QuickDASH (25) and lower MHQ (68.3) scores, highlighting the influence of systemic trauma and the timing of reconstruction on functional recovery.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eChoice of Donor Toe\u003c/h2\u003e\u003cp\u003eGreat toe transfer has historically been considered the most reliable option for providing both length and bulk (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). However, disadvantages include significant donor site morbidity due to disruption of the windlass mechanism (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). The second toe transfer, as utilized in our series, provides adequate length with lower donor site morbidity and is often favoured when aesthetics, gait preservation, or cultural concerns preclude great toe harvest. While some studies report inferior grip and pinch strength compared with great toe transfers (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), our findings confirm that second toe transfer can achieve satisfactory hand function in carefully selected patients.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eLevels of the Amputation and Reconstruction Strategies\u003c/h2\u003e\u003cp\u003eThe level of thumb amputation strongly influences reconstructive planning. At the carpometacarpal (CMC) level, challenges include restoring both length and web space. Authors such as Sabapathy have advocated staged procedures using groin flaps combined with delayed toe transfers (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Others have described combined free tissue flaps (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). These multistage reconstructions increase morbidity, cost, and operative time. In contrast, our approach of single-stage second toe transfer, even at the CMC level, yielded acceptable functional and sensory outcomes with QuickDASH scores as low as 6.4, supporting the feasibility of this strategy in resource-limited settings.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eTiming of Reconstruction\u003c/h2\u003e\u003cp\u003eThe use of immediate versus delayed toe transfer continues to be debated. Early reconstruction allows the restoration of length and function before soft tissue contracture sets in, whereas delayed procedures permit staged wound conditioning and optimize recipient vessel availability. In our cohort, patients reconstructed within weeks of injury (Case 1, Case 4) demonstrated superior patient-reported outcomes compared than those underwent delayed procedures after several months (Case 3, Case 5). These findings align with the reports of Adani et al., who reported better sensibility and functional scores in immediate versus delayed transfers (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eSecond toe-to-thumb transfer remains a reliable and functionally effective option for thumb reconstruction, particularly in cases of proximal amputations where other techniques are limited. Despite the financial burden and technical demands in resource-constrained settings, this series demonstrated favourable sensory and functional outcomes, highlighting its role as a viable reconstructive option in carefully selected patients.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eMHQ:\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eMichigan Hand Outcomes Questionnaire; DASH: Disabilities of the Arm, Shoulder, and Hand; CMC: carpometacarpal; MCP: metacarpophalangeal; RTA: road traffic accident; mm: millimeter\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eThis study was conducted in accordance with the ethical standards of Helsinki declaration and its later amendments. Ethical approval was obtained from \u003cstrong\u003eLiaquat National Hospital Ethical Review Committee\u003c/strong\u003e (approval no. 1021-2024-LNH-ERC). Written informed consent for participation and publication of identifiable information and images was obtained from all patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish\u003c/strong\u003e: Written informed consent was obtained from the patients for publication of their clinical details and accompanying images.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eThe raw data supporting the findings of this study are not publicly available due to hospital confidentiality policies and ethical restrictions, as they contain patient medical information. De-identified data may be made available from the corresponding author on reasonable request and with permission from Liaquat National Hospital.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest:\u0026nbsp;\u003c/strong\u003eThe authors declare no conflicts of interest\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis study did not receive any external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions:\u0026nbsp;\u003c/strong\u003eA.Q.: Conceptualization, literature review, data collection, data analysis, methodology guidance, manuscript editing; O.S.: literature review, original manuscript draft; R.A.: critical revision of manuscript; O. R.: supervision, reviewing. All authors approved the final version of manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u0026nbsp;\u003c/strong\u003enot applicable\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e: not applicable.\u0026nbsp;\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCobbett JR. Free digital transfer. Report of a case of transfer of a great toe to replace an amputated thumb. J Bone Joint Surg Br. 1969;51(4):677\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBuncke HJ Jr., Buncke CM, Schulz WP. Immediate Nicoladoni procedure in the Rhesus monkey, or hallux-to-hand transplantation, utilising microminiature vascular anastomoses. Br J Plast Surg. 1966;19(4):332\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMorrison WA, O\u0026rsquo;Brien BM, MacLeod AM. Thumb reconstruction with a free neurovascular wrap-around flap from the big toe. J Hand Surg. 1980;5(6):575\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWei FC, Chen HC, Chuang CC, Chen SH. Microsurgical thumb reconstruction. J Hand Surg [Br]. 1984;9(3):223\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYang DY, Gu YD. The report of free second toe transfer for thumb reconstruction in 4 cases. Chin J Surg. 1977;15:1\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFriedrich JB, Vedder NB. Thumb reconstruction. Clin Plast Surg. 2011;38(4):697\u0026ndash;712.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDonnelly MR, Bekisz JM, Rocks M, Medrano BG, Mayer J, Pan JD, Hacquebord JH. General population and surgeon preferences for pollicization versus toe-to-thumb transfer for reconstruction of traumatic thumb loss in adults: An international, multi-center survey study. J Hand Surg. 2024;49(10):1034e1.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWei FC, Chen HC, Chuang CC, Noordhoff MS. Reconstruction of the thumb with a trimmed-toe transfer technique. Plast Reconstr Surg. 1988;82(4):506\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWei FC, Colony LH, Chen HC, Chuang CC, Noordhoff MS. Combined second and third toe transfer. Plast Reconstr Surg. 1989;84(5):651\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMorrison WA, O\u0026rsquo;Brien BM, MacLeod AM. Experience with thumb reconstruction. J Hand Surg [Br]. 1984;9(3):223\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFoucher G, Moss AL. Microvascular second toe to finger transfer: A statistical analysis of 55 transfers. Br J Plast Surg. 1991;44(2):87\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChung KC, Wei FC. 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J Burn Care Rehabilitation. 2004;25(2):138\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKrabbe-Timmerman IS, Daryousch I, Azzopardi EA, et al. Outcomes of toe-to-thumb transfer in adults: A systematic review. J Hand Surg Eur Volume. 2016;41(5):492\u0026ndash;500.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAdani R, Busa R, Castagnetti C, Caroli A. Delayed versus immediate toe-to-hand transfer in traumatic amputations. Microsurgery. 2003;23(1):35\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Toe-to-thumb transfer, Microvascular, Traumatic thumb amputation, Resource-limited setting","lastPublishedDoi":"10.21203/rs.3.rs-7768763/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7768763/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTraumatic thumb amputations significantly impact daily living and quality of life, and effective reconstructive solutions are needed. This case series evaluated the functional and surgical outcomes of second toe-to-thumb microvascular reconstruction in patients with traumatic thumb amputations, performed at a tertiary care hospital in Karachi, Pakistan.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMaterials and methods\u003c/b\u003e\u003c/p\u003e\u003cp\u003eBetween 2018 and 2023, five patients underwent second toe-to-thumb transfer, and outcomes were assessed via the Michigan hand outcome questionnaire (MHQ), QuickDASH, and static two-point discrimination.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAll patients achieved satisfactory functional recovery, with QuickDASH scores ranging from 4.5\u0026ndash;25 and MHQ scores ranging from 68.3\u0026ndash;83.6. Sensory recovery, measured by two-point discrimination ranged from 8 to 10 mm. The study highlights the viability of second toe-to-thumb as a reliable reconstructive option, even in resource limited settings. Moreover, these findings emphasize the importance of early intervention, as patients with shorter delays between injury and reconstruction have better outcomes.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis case series contributes to the global literature by providing region-specific evidence for thumb reconstruction and underscores the feasibility of complex microvascular procedures in challenging healthcare environments.\u003c/p\u003e","manuscriptTitle":"Functional and Surgical Outcomes of Second Toe-to-Thumb Microvascular Reconstruction: A Case Series from a Tertiary Care Hospital in Karachi, Pakistan","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-24 10:27:01","doi":"10.21203/rs.3.rs-7768763/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d5c20389-1641-49dc-8b44-e98e22643500","owner":[],"postedDate":"November 24th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-29T16:09:45+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-24 10:27:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7768763","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7768763","identity":"rs-7768763","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}