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altelis
Mountain climber
NM
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Quantum7, I just finished up my Ortho residency at the University of New Mexico. One of our attending surgeons there did a few of those pollicization reconstructions.
We have a lot of cowboy roping accidents (in fact, one of our other attendings has published many papers on thumb amputations from roping accidents).
I've taken care of many patients with thumb and/or hand amputations, and discussed with them getting back to manual labor type jobs (roping, ranching, and carpentry for the most part) with both myoelectric prosthetics as well as with pollicization reconstruction.
The few carpenters who've had isolated thumb or thumb/index amputations and had pollicization really like the end result. Depending on the level of amputation it can be a very functional thumb.
The young cowboy's we've had who've needed myoelectric prostheses (typically for more hand based, rather than finger based, amputations) have been overall happy with their prostheses and ability to get back to a lot/most of their jobs. But pretty sure all would trade them in for a more functional and durable thumb.
Its not a surgery that's done frequently, so if it is a possibility for you I would strongly recommend finding a hand surgeon at a center that has a lot of experience with these injuries.
If I can be a resource at all for you, I'd love to help however I can.
a l te l is at gmail dot com
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altelis
Mountain climber
NM
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Haha Gnome- this is where I come when the long days and weeks prevent me from getting into the mountains as much as I'd like.
Plus, while I can go on forever when I feel like I have some level of experience to add to the conversation, in this community my climbing experience (while certainly not negligible) is dwarfed by you all. I read and enjoy and try to learn. But when on occasion something orthopedic comes up, I like being able to pretend like I have something to offer ;)
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altelis
Mountain climber
NM
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The big toe actually has a very important role in walking.
That being said, your thumb, especially if you rely on your hands for work or pleasure or both, plays a much more important role.
There are relatively easy additions to shoes (e.g. carbon fiber shank with morton's extension) that can help make up for the loss of a big toe. There are not very good easy additions to make up for a lost thumb.
Certainly you won't need an actual prosthesis, and depending on the stiffness of your shoe, may not even need anything in your shoes.
My hunch is the biggest thing that will be noticed with a great toe amputation for climbing is the lack of sensitivity/feeling. Most of us use our big toe as the point of maximum feedback and purchase while climbing.
I'm sure you'd be able to find an orthotist who likes to climb that would work with you to make a custom orthotic for a climbing shoe. I'd guess moving toward a slightly stiffer climbing shoe with a more symmetric toe box (e.g. less reliant on all your weight being on your great toe) would be what you'd want.
But overall those are going to be minor and easy things to overcome compared to the possibly massive advantages of having a functional thumb again.
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nafod
Boulder climber
State college
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Years ago there was an F14 pilot, call sign Hoser, who lost his thumb. Had the surgery and was able to return to flight status (with new callsign = Toser). Pretty stringent requirements on reach and mobility required to satisfy the docs, as you can imagine.
Best of luck...
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quantum7
Trad climber
Squamish
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Topic Author's Reply - Jul 7, 2018 - 07:56am PT
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Thanks again for the responses. Scott and Strawberry Rhubarb, sent you both PMs. Altelis, I have some Qs for you as well, but need to gather my thoughts. I tried climbing a week ago (on TR) with my hand in a glove. It's not easy, but I tried. Big problems are: can't clean gear (let alone place it) with my right hand; belaying is not smooth (trying to learn to use the gri gri with my left hand as I am not comfortable with the ATC); fingers are still way too sensitive to place in crack or crimp.
But, in three and a half months I have definitely seen improvement in every day life tasks, which is why I am questioning the toe transfer. I have surgery booked in the fall, so still time to change my mind. My job definitely requires a working hand as does climbing, but so much fear that my foot will be compromised or that the transfer will fail (small possibility) and I could be thumbless and toeless.
Thought I would include a picture so you have a sense of what I am talking about.
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altelis
Mountain climber
NM
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Keep using it! A lot of that sensitivity will go away with use. And I totally agree, figuring out the bounds of what you can do as is will really help you decide if pollicization is worth the sacrifice to your feet.
I can't tell from the picture, were they able to salvage the base of the 1st metacarpal? As in, do you still have a thumb basal joint (the 1st CMC joint)? If so, and there may be other options to give you a slightly longer stump without sacrificing a toe. The longer stump wouldn't have the ability to flex at the IP joint, but if the thumb basal joint is still working then you may be able to retain opposition and abduction which could give you a good in between option.
Happy to answer any questions whenever you are able to get your thoughts together.
And biggest thing I would suggest is make sure you are seeing an experienced hand surgeon who has experience doing post-traumatic hand reconstructions. If that's not your current surgeon, ask for a referral for a second opinion. Any good surgeon should be happy to help find you a second opinion.
We do a lot of hand surgery and reconstruction during my residency, but we have hand fellows and they get most of the actual (excuse the pun) hands on surgical time during those cases, and not the residents. I'm going to be in LA starting next month doing a trauma fellowship, so while this isn't going to be my speciality, I definitely understand the concepts fairly well and can either ask my mentors from residency and/or refer you to any resources available if I don't know the answer myself.
~Alex
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nafod
Boulder climber
State college
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Ok, found the link. On Hoser. You can see the right hand has 3 fingers and a big toe. Plenty of tactile action required to fly.
https://m.youtube.com/watch?v=6aILfg1KRcg
[Click to View YouTube Video]
https://www.facebook.com/120434031325043/posts/%22in-the-smoke-'till-i/3798057326364/
Around 1986 Hoser "procured" a 20MM barrel from the F-14 Gatling gun. He attached a breach and fashioned himself a rather formidable weapon. One day the breach blew up, took off his index finger and right thumb. That would not stop Hoser, he had them take off his right big toe and attach it to his right hand....now he had three fingers and a big toe...looked a bit like a lobster. He proved he could operate the trim button on the stick and back on flight status he went...oh and with a new call sign, "Toeser"....you just can't make this stuff up.
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spectreman
Trad climber
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I'm an outpatient physical therapist of 30 years. I've seen several patients with amputated big toes. They all compensated very well and were able to walk normally. It took some time and some work but they all did very well.
Good luck to you!
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the Fet
climber
Tu-Tok-A-Nu-La
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Maybe you could put some athletic tape under the toe over the top, over the top of the foot and back around the ankle to pull the toe up hyperextended to get a feel of what it would be like without it.
If I were in your situation I’d likely do it. Except my big toe is monstrous so it would be really freaky. I have a friend where they used a pinky to replace a thumb. It works well for writing etc but I’d prefer the strength of the big toe for climbing etc.
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quantum7
Trad climber
Squamish
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Topic Author's Reply - Jul 8, 2018 - 06:51am PT
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@Alex - |I have my MCP joint intact, thankfully.
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micronut
Trad climber
Fresno/Clovis, ca
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I'll definitely defer to the orthopods here, but my quote about the big toe not being all that necessary for walking comes from three personal friends who dont have one. I know that's not much of a sample size, but each of them seems to have little to no issue.
So I should have said....."None of the three friends of mine without a big toe said it cauuses much trouble walking without it."
The whole point was to offer some encouragement from personal direct experience.
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altelis
Mountain climber
NM
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Micronut- sorry if that came out too much as a disagreement with your friends' experiences.
Absolutely, I would agree that most people will eventually get along just fine without a big toe.
But it does serve some sort of purpose, and there are definitely activities that are easier with one.
And while the pollicization is generally very successful, its not 100%, and the new thumb does have limitations.
Quantum is clearly torn, and I just didn't want to (overly) minimize the loss of a fully functioning body part nor (overly) sell on the benefits of the surgery.
I think he's in the right place- trying to really get a good sense for what his current hand can do, and really understand the pros/cons of the surgery.
The honest answer- I'd defer most to folks personal experience with the surgery, loss of a big toe, and the therapists on the board who have experience treating patients who've either had this surgery or are without a big toe.
~Alex
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High Fructose Corn Spirit
Gym climber
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I've been following this thread.
As an outside third party, I just want to thank Altelis for posting up and sharing his expertise. Thanks to the two or three others too who did so as well - and thank you too, Micronut. I always find your posts in these medical and health matters accurate/informative.
Good luck, quantum7. See you in the mountains and crags!
https://en.wikipedia.org/wiki/Pollicization
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micronut
Trad climber
Fresno/Clovis, ca
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Alex no problem at all! I appreciate your wisdom and would trust you over most of us who have no experience with these kind of things. Glad you are on here for your insight and experience. I hope he gets some good intel from credible sources.
As a surgeon myself (gums and jaw and sinus though......I know nothin' bout toes!), I agree that trading a totally viable limb for a surgery that is not guaranteed is a decision only he can make. Hopefully he is able to surround himself with a good medical team that can help with this decision.
Good luck and keep us in the loop Quantum!
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micronut
Trad climber
Fresno/Clovis, ca
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I have reached out to my buddy Curtis and he is going to send me some photos of his foot and his hand. I will also have him chime in with his direct experience.
Scott
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Gimp
Trad climber
Missoula, MT & "Pourland", OR
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Given the deficits shown toe transfer would be preferable to pollicization IMO. I have done both operations multiple times over my career and while all patients are fearful of the morbidity of toe loss I (despite believing you should rarely if ever say always and never in medicine) all my patients ultimately were happy about their decision for toe transfer.
I stopped doing toes 5 years ago as I began to move out of trauma and into a more age appropriate elective hand practice so would not claim to be totally up to date on the all the various modifications of great toe transfer currently available. But a trimmed toe looks like the most likely choice for you given the level of your amputation. Busy centers usually have patients who have had the procedure who are willing to discuss their experience you may want to ask about this.
I concur with prior comments regarding going to a volume microsurgery center for this procedure. The Bunke clinic in San Francisco is now run by the late Harry Bunke's son Greg and the clinic is very focused on microsurgery and has excellent outcomes. In Canada Toronto used to be the center for all things microsurgical but suspect there are many well trained people at many sites throughout the country now.
Good luck with your decision making. Get more than one opinion and realize you have time to make this decision.
Steve
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Gunkie
Trad climber
Valles Marineris
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quantum7, sorry for your accident. I hope things work out for you. With that said, I am continually amazed at the depth of knowledge, experience and competency displayed on ST.
Carry on.
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Gnome Ofthe Diabase
climber
Out Of Bed
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Hmmm I spoke to mouse, he is readin; Kraus, my mentor & so much more.
Hans had the 1st family,to attend to, for JFK's back, complicated by Addison's, so recuperation was in doubt.
Thats the un-known, how do you think you will heal? and is running close to your heart, the controller of .... all that running is, (to many)
long distance or any running becomes , for some, a near daily need
As in, is to be able to run, a must?
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altelis
Mountain climber
NM
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Steve, thanks for the input.
Looking back at my posts, I had meant to initially talk a second about pollicization and then continue recommending toe transfer. But realized I kept using pollicization in my discussion.
I'm a little dazed from studying for Boards this Thursday.
I fully agree, given his amputation (both thumb and other digits) and desired functionality if he goes forward with surgical reconstruction, toe-transfer is the way to go.
Sorry to any who I confused with continued use of the term pollicization.
Steve, are you still working in Missoula?
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