traumatic loss of thumb leads to significant loss of function as the thumb contributes to about 40% of the hand functions . when the loss is bilateral , it is more devastating .
replantation is indicated in all cases ; however , may not be possible in cases with unsuitably amputated thumb .
toe to thumb transfer is an excellent option in these patients and helps restore both function and esthetics.[14 ] we have performed a bilateral second toe to thumb transfer in a patient who underwent bilateral traumatic thumb amputation .
a 25 year old male presented to our department with the traumatic amputation of both the thumbs distal to the metacarpophalangeal ( mcp ) joint , and at the proximal 1/3 of the proximal phalanx while working on punch press machine [ figure 1 ] .
the amputated parts were not replantable . after discussing the pros and cons of the different modalities of reconstruction ,
within 12 hours of the injury , the left second toe was transferred to the right thumb . a week later , the right second toe was transferred to left thumb .
preoperative view of amputated bilateral thumbs surgery was performed under the combination of spinal , epidural and brachial blocks , and was supplemented with intravenous general anaesthesia .
v shaped incision was taken at the base of the second toe and extended proximally .
the slip of extensor digitorum longus ( edl ) and the deep peroneal and dorsal digital nerves , were dissected proximally .
the plantar dissection was started by taking  a v shaped incision extending proximally up to the instep area .
plantar digital arteries and nerves were identified and proximal intraneural dissection was done . the flexor hallucis longus ( fhl ) tendon was dissected proximally for adequate length .
vascularity to the toe was confirmed after the release of tourniquet . at this stage ,
the dorsal branch of the radial artery , its venae comitantes , tributary of cephalic vein , the dorsal digital nerve and the proximal end of the extensor pollicis longus ( epl ) were explored and tagged . through volar incision , flexor pollicis longus ( fpl )
the toe was separated by ligating the pedicle and transferred to recipient site [ figure 2 and 3 ] . after removing the articular surface of donor toe proximal phalanx ,
flexor and extensor tendons were repaired [ flexor digitorum longus ( fdl ) to fpl , extensor digitorum longus ( edl ) to epl ] .
bilateral plantar digital nerves were coapted to volar digital nerves of the thumb , and the dorsal digital nerve was coapted to the dorsal digital nerve of thumb . the medial arch vein and venae comitantes of donor toe were anastomosed with a tributary of cephalic vein and venae comitantes of the radial artery , respectively .
residual raw areas on the radial and ulnar aspect of the reconstructed thumb were grafted [ figure 4 ] .
plantar view of harvested second toe dorsal view of harvested second toe intraoperative view of second toe transferred to thumb .
also seen the grafted the area to avoid wound closure with undue tension the second metatarsal was shortened .
the gap between the first and third toe was reduced by repair of intermetatarsal ligament and transverse k wire .
a similar procedure was carried out for the reconstruction of the left thumb using the right second toe . in the right foot , fdma was plantar dominant .
rehabilitation : after 3weeks , the k wires were removed , and the patient was supervised daily .
physiotherapy in the form of active flexion and extension was started and continued for 2 months .
patient had a recovery of protective sensation at 8 months , and was advised to resume his normal duties .
functional assessment at follow up at the end of 1 , 2 & 3 years is shown in table 1 , and in figures 57 .
the patient is back to the same occupation , & has no disability or restricted flexion in terminal joint on the left sside ; hence no further surgery has been carried out .
functional assessment of the patient in the reported case study with bilateral second toe to thumb transfer , at follow up 
 at the end of 1 , 2  3 years good function achieved after toe transfer excellent strength achieved after toe transfer(right thumb ) excellent strength achieved after toe transfer ( left thumb )
surgery was performed under the combination of spinal , epidural and brachial blocks , and was supplemented with intravenous general anaesthesia .
v shaped incision was taken at the base of the second toe and extended proximally .
superficial dorsal veins were dissected . the first dorsal metacarpal artery ( fdma ) was seen dorsal to the dorsal interosseous muscle , and dissected proximally .
the slip of extensor digitorum longus ( edl ) and the deep peroneal and dorsal digital nerves , were dissected proximally .
the dorsal branch of the radial artery , its venae comitantes , tributary of cephalic vein , the dorsal digital nerve and the proximal end of the extensor pollicis longus ( epl ) were explored and tagged . through volar incision , flexor pollicis longus ( fpl ) proximal end and digital nerves
the toe was separated by ligating the pedicle and transferred to recipient site [ figure 2 and 3 ] . after removing the articular surface of donor toe proximal phalanx ,
flexor and extensor tendons were repaired [ flexor digitorum longus ( fdl ) to fpl , extensor digitorum longus ( edl ) to epl ] .
bilateral plantar digital nerves were coapted to volar digital nerves of the thumb , and the dorsal digital nerve was coapted to the dorsal digital nerve of thumb . the medial arch vein and venae comitantes of donor toe were anastomosed with a tributary of cephalic vein and venae comitantes of the radial artery , respectively .
residual raw areas on the radial and ulnar aspect of the reconstructed thumb were grafted [ figure 4 ] .
plantar view of harvested second toe dorsal view of harvested second toe intraoperative view of second toe transferred to thumb .
the gap between the first and third toe was reduced by repair of intermetatarsal ligament and transverse k wire .
a similar procedure was carried out for the reconstruction of the left thumb using the right second toe . in the right foot , fdma was plantar dominant .
rehabilitation : after 3weeks , the k wires were removed , and the patient was supervised daily .
physiotherapy in the form of active flexion and extension was started and continued for 2 months .
patient had a recovery of protective sensation at 8 months , and was advised to resume his normal duties .
functional assessment at follow up at the end of 1 , 2 & 3 years is shown in table 1 , and in figures 57 .
the patient is back to the same occupation , & has no disability or restricted flexion in terminal joint on the left sside ; hence no further surgery has been carried out .
functional assessment of the patient in the reported case study with bilateral second toe to thumb transfer , at follow up 
 at the end of 1 , 2  3 years good function achieved after toe transfer excellent strength achieved after toe transfer(right thumb ) excellent strength achieved after toe transfer ( left thumb )
reconstruction of the thumb requires careful evaluation and discussion of the patient 's occupational and social profile , and the treatment options available .
microvascular toe transfer has become an invaluable tool to restore hand function in such patients .
the advantage of second toe transfer is minimal donor site morbidity , excellent appearance and good function , making it the preferred digit for use for thumb transfer .
however , it is important to consider this in the indian population as many here people walk barefoot or wear chappels . in our case , after discussing all the reconstructive options , a decision to perform a bilateral second toe transfer was taken .
the surgery is of long duration , and also places significant physiological demands on the patient , and hence was performed in two stages .
this was done to ensure the definitive survival of the transferred toe , and also as we do not expect any vascular event beyond one week . during the second surgery as well , the pedicle dissection has to done carefully , as the course of the fdma may be different here and not necessarily similar to the first surgery .
also , precautions need to be taken to maintain the proper tensioning of the tendons , and from an esthetic point of view , the same length of the reconstructed thumbs needs to be maintained on both the sides .
we had a long term follow up ( defined as > 3 years ) for the patient , as by this time the neural recovery is almost complete , and most of the adaptation to the newly reconstructed thumb has occurred . in our case ,
thus to conclude , bilateral second toe to thumb microvascular transfer restores excellent hand function with minimal morbidity in the foot [ figure 8 ] . primary toe transfer , not only decreases the convalescent period and the medical costs , but also ensures early return to work . besides , it gives bilaterally symmetrical and aesthetically pleasing thumbs [ figure 9 ] . minimal donor side morbidity which goes unnoticed excellent strength achieved after toe transfer
 in bilateral thumb amputations , the functional impairment is serious and every attempt should be made to reconstruct the thumb . 
 we report a case of bilateral post traumatic thumb amputation , reconstructed with bilateral second toe transfer . 
 only two such cases have been reported in literature so far . 
 though there are various modalities for the reconstruction of thumb , microvascular toe transfer has its own merits . 
 the convalescent period is minimal with excellent function . 
 it is bilaterally symmetric and aesthetically superior to the osteoplastic reconstruction . 
 the technical details are discussed , and the long term functional and aesthetic results are presented . 