American Society for Peripheral Nerve

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Investigating patient attitudes towards microvascular free toe flap reconstructions: a guide for surgeons during informed consent
Johnny Ionut Efanov, MD; Christopher Wong, MD; Clarence Guilbault, MD; Ali Izadpanah, MD; Michel A Danino, MD PhD; University of Montreal's Hospital Centre (CHUM), Montreal, QC, Canada


In patients with traumatic finger and thumb defects, restauration of an aesthetic contour and gain of sensory or motor functions can be accomplished with microvascular free toe flaps. The high survival rate of this technique encouraged many surgeons to offer it for various indications. However, many patients in clinical practice opt for alternative treatments when presented with this option. The goal this study was to determine patients' attitudes with respect to free toe flaps and to investigate areas of informed consent that need to be addressed.

Material & Methods

An in-house survey was conceived and administered prospectively to patients with traumatic finger amputations not amenable to emergency replantation. Patients were recruited after undergoing amputation revision in a regional replantation referral centre. Participants were required to complete an online survey with four components: patient demographics, Brief Michigan Hand Questionnaire (bMHQ), utility questionnaire using the standard gamble/time trade-off techniques and a questionnaire investigating potential reasons for refusal to partake in a free toe flap operation.


A total of 30 patients were enrolled in the study. Mean age was 47.5 ranging from 27 to 78 with a greater representation of men (90%, n=27). Amputations occurred mostly in the context of cooking, house chores and hobbies (80%, n=24) and affected the non-dominant hand (60%, n=18). Mean score on the bMHQ was recorded as 83.3, with a range from 54 to 96. Utility questionnaires yielded mean measures of 0.85 and 0.9 on the standard-gamble and time trade-off respectively. From a list of 14 reasons why patients would opt out of a free toe transfer, a majority of patients (70%, n=21) stated flap failure as a major source of concern, followed by lack of clarity for risks and benefits during informed consent (63%, n=19) and by perception that foot function will be affected (50%, n=15). Cultural/religious beliefs and complexity of rehabilitation were not reported as reasons for refusal to undergo free toe flaps in 80% (n=24) and 53% (n=16) of patients respectively.


A better understanding of patients' attitudes and beliefs with respect to free toe flaps will allow surgeons to better address these issues during informed consent. This survey emphasizes the importance to discuss about failure rates, risks and benefits of the operation and donor site morbidity of the foot.

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