Reply: Toe Transfers Outperform Replantation after Digit Amputations: Outcomes of 126 Toe Transfers

We thank Karamitros et al.1 for their letter regarding our recent study. We appreciate that our study2 has reignited interest in toe transfers. It is, however, not replantation that is in danger of becoming obsolete, but toe transfer, a reconstructive option that has quietly disappeared from many centers. Media interpretation should be guided by what is actually written in our article. As stated clearly in our Discussion section, replantation should always be attempted where appropriate. There are already excellent data demonstrating that replantation achieves superior outcomes to revision amputation,3,4 yet this has not been used to strengthen national policy or training priorities. The decline in replantation rates in the United States, therefore, reflects a long-standing policy gap, not our findings. Some commentators have argued that “not all confounders were included,” but this reflects a misunderstanding of causal adjustment. The aim is not to include every conceivable variable but to adjust for those theoretically justified and avoid overfitting. Our model adjusted for principal confounders derived from the largest comparative study of replantation—age, sex, and injury pattern.4 Injury etiology was not included in a priori analyses, as it was not considered relevant to elective toe transfer where zone of injury can be excised. We had considered a propensity-matched approach, but the necessary covariates were not specified nor obtainable from the Finger Replantation and Amputation Challenges in Assessing Impairment, Satisfaction, and Effectiveness study (a multicenter study comparing replantation with amputation).3 More importantly, general linear models facilitate post hoc pairwise comparisons across injury subtypes and retain power that would be lost in 1:1 matching. Thus, it represents a transparent and reproducible analytical alternative, not a methodological shortfall. To assess robustness, we performed additional post hoc sensitivity analyses, including injury etiology, dominant hand, occupational change, and injury year. This, again, favored toe transfer, with a large effect size exceeding minimum clinically important differences (adjusted Michigan Hand Outcomes Questionnaire mean: replantation 55.7 versus toe 77.4, P = 0.002). These results are not artifacts of model choice or residual confounding; they are consistent, strong, and reproducible. Since the pioneering toe-to-thumb transfer by Cobbett in 1968, our study remains the first and only large comparative analysis of toe transfer versus any other treatment.2 Few have employed validated patient-reported outcome measures. We have been transparent about our study limitations and encourage replication using other datasets, particularly from the United States. As our colleagues rightly noted, toe transfers and replantation are not competitors. The real question, and key message of our article, is what happens to patients left with an unreconstructed amputation, a group representing one of the largest global disability burdens in the Global Burden of Diseases Study framework?5 Should they simply be told that no reconstructive solution exists? Health policy is the next frontier. Toe transfer is technically feasible and scalable. To to suggest otherwise reflects a persistent bias that underestimates microsurgical capabilities worldwide, particularly in low- to middle-income countries. In India, annual free flap volume has grown from fewer than 200 free flaps per year in the 1990s to more than 250 per day today.6 What remains lacking is policy evidence that quantifies disability-adjusted life-year savings and cost-effectiveness at accepted willingness-to-pay thresholds. That is where the field must now focus. DISCLOSURE The authors have no financial interest to declare.