Successful Reconstruction of Bilateral Thumb Amputations in a Soldier Using Toe-to-thumb Transfer and Index Pollicization

Summary:

The thumb contributes nearly half of overall hand function, and its loss is profoundly disabling. Bilateral thumb amputation is rare and catastrophic, often necessitating complex reconstruction. Toe-to-thumb transfer is considered the gold standard, whereas index pollicization is a powerful alternative when microsurgical transfer fails. This report describes a rare case of bilateral thumb amputation managed with both techniques, highlighting their complementary roles. A 32-year-old right-handed soldier sustained bilateral thumb amputations from a high-velocity gunshot injury while holding a sniper rifle. On arrival, both thumbs were amputated at the proximal metacarpals with exposed bone, though the remaining fingers and systemic evaluation were intact. He underwent bilateral second toe-to-thumb transfers. The left reconstruction remained viable and fully functional, but the right developed ischemic necrosis. Salvage included repeated debridements, vacuum-assisted closure therapy, free anterolateral thigh flap coverage, and a groin flap with scar revision. Functional restoration was later achieved with index pollicization, followed by flap debulking and liposuction. At the final follow-up, both reconstructions demonstrated a full range of motion and opposition. The patient reported the pollicized right thumb to be subjectively stronger and more reliable than the contralateral toe transfer, enabling independence in daily living with satisfactory functional and aesthetic outcomes. This case illustrates that even when microsurgical toe transfer fails, staged salvage with flap coverage and index pollicization can restore bilateral function. The coexistence of both reconstructions in one patient provided a unique comparison, highlighting their complementary strengths.