Toe-to-hand surgery gives man new lease of life

In 2005, 20 bright-eyed medical students boarded a plane to the US and Europe for an elective term to gain exposure to first world medicine.

For many, it was their first time to fly and they were all excited to see the world beyond the small town they had spent the last four years training to be doctors. We were all placed in various cities in pairs or in groups of four and we set out to make the best of our experience and learn novel things while at it.

The noble programme was set up as part of the established partnerships between Moi University School of Medicine and multiple prestigious medical schools in the US, Sweden and the Netherlands.

The venerable Prof Joe Maamlin and his wife Sarah steered the programme with utmost dedication and though we did not quite understand it then, it was truly a privilege.

My classmate and I landed in Portland, Oregon on a wet and chilly evening at the tail end of winter after 26 hours of flying and transit. We were welcomed by familiar faces, a team of doctors who had just previously been on rotation at Moi University and this helped ease us into our temporary new life.

MISSING THUMB

The first orientation we got was that it always rained in Portland, hence it was easy to tell the visitors apart from the locals: only visitors carried umbrellas, everyone else walked in the rain.

Our first hosts were a lovely couple who owned a highly territorial cat. The lady was the doctor, doing her residency in internal medicine at the hospital we were rotating at. Her husband was an engineer who was originally from Alaska and could not tolerate temperatures above 18 degrees Celsius. He had lived all his life in sub-zero temperatures back home in Anchorage.

Their home was the classic American suburban middle class home with a white picket fence in a street with neatly arranged blocks. There was a little bodega (an equivalent of an estate kiosk) up the street, ran by Miguel*, a Mexican gentleman, who played soft salsa music all day. We would stroll there in the evenings after dinner as spring crept in and the light hours got longer, for a tub of ice cream to serve as our dessert.

Despite numerous trips there, I never noticed anything unique about Miguel until my host brought it to my attention. She asked me if I had noticed Miguel’s “thoe”. I had no idea what she was talking about. She went on to explain that Miguel previously worked in an industrial warehouse. He accidentally severed his right thumb to a rotating machine, leaving him suddenly significantly disabled and traumatised. It was not possible to save the thumb.

For two years, Miguel lived with his disability, losing the ability to earn a decent living. He had to learn to use his left hand for such important tasks as writing and feeding, but he couldn’t get over the reactions his thumbless hand drew when he offered a handshake. He became withdrawn and depressed.

It was, therefore, quite a relief for him when he was given a second chance at regaining a semblance of his life, to restore his thumb function. However, for this to happen, he would have to give up another body part, one of his toes. It was a decision he made in a heartbeat. There was no hesitation. He could live with a missing toe, but not a missing thumb.

Miguel was checked in to the hospital with a lot of trepidation. He was immensely hopeful that he would finally be able to reclaim his life, but a big part of him was scared. Scared to hope and have that hope dashed by a failed attempt at such a rare surgery.

Miguel’s fears remained unfounded as he came out of the operating room several hours later with a bulky dressing on his hand and a second one on his right foot. He could not wait to meet his new “thoe”, his name for his new thumb fashioned out of a toe.

Four days later, the doctors gave him a clean bill and discharged him. Intensive follow-up was required to ensure the toe took to its new home well without infection while occupational therapy ensured a smooth transition of roles. Six months later, Miguel set up the bodega as proof that he was fully functional.

DONATING FOOT

Toe to hand transplant surgery is an ancient medical art first pioneered in the late 19th century by a brave Nicoladoni. It is a mystery how the transplant was successful in an era before the microscopic human anatomy was well appreciated. The modern transplant surgeries gained popularity almost 70 years later and have gone on to restore hope to dozens of men and women around the world.

Though a toe can be used to replace any finger on the hand of the same side of the body, the thumb is the most significant due to its functions. The surgery involves highly technical miscrosurgery skills to be able to maintain proper blood flow in the transplanted toe and regain near-perfect sensation. There is no grasp or grip or pinch without the thumb. It plays a major role in sensation and in fine motor function that is necessary for life. Imagine not being able to sign a cheque or hold your toothbrush or pick at your favourite peanuts for the rest of your life.
The preferred toe for transplant is usually the second one due to its size. It is easily adaptable and more aesthetically appealing.

This also minimises disability of the donating foot. The patient is able to maintain a near-normal gait unlike if the big toe was harvested. However, this may limit one from certain sporting activities.

You can bet the very next morning I found an excuse to visit Miguel’s enterprise to catch a glimpse of his miracle. It dawned on me that even just counting money at the cash desk was not something Miguel would have been able to do without his “thoe”.

Dr Bosire is an obstetrician/gynaecologist