|Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.|
| FIG. 2. Transplant No. 1
A, Entire hallux mobilised on superficial dorsalis pedis artery and lateral malleolar vein. Extensor hallucis longus, flexor hallecis longus, and nerves cut long and marked.
B, Hallux free, tendons, nerves and vessels tagged.
C, Small tapered plastic tube inserted into artery to flush transplant with Heparin-saline solution, 200 units per ml.
D, Free hallux placed by hand.
E, Thumb amputated after isolating and tagging radial artery, cephalic vein, nerves, extensor pollicis longus and flexor pollicis longus.
F, Hallux stabilised with a pin across the metatarsonavicular joint, ready for tendon, vascular, nerve hook-up.
G, Distal end of superficial dorsalis pedis, and proximal end of radial arteries brought into atraumatic double vascular clamp for anastomosis.
H, Completed anastomoses - artery left, vein right.
I, Upper extremity in cast, distal phalanx of hallux exposed for periodic examination.
Method.-Induction anaesthesia was produced by intravenous Nembutal 0.2 g. per lb., and supplemented with open drop ether and an oral airway. A bloodless field was created with an Esmarch bandage and a newborn infant sphygmomanometer on the arm and an infant cuff on the leg. The superficial dorsalis pedis artery was exposed on the dorsum of the ankle and dissected distally to the level of the metatarsal cuneiform joint. All adventitia and venae comitantes were stripped from the vessel. The medial malleolar branch of the posterior saphenous vein, or the lateral malleolar branch depending on which was the larger, was mobilised in a similar fashion.
Transplant No. 2 Fig. 3-A, Hallux amputated, structures tagged. B, Large hallux and small thumb beside recipient wound on hand. C, Hallux pinned in thumb position.
Fig. 4-Arteriogram of transplant No. 1 at two weeks showing complete filling of the vessels in the " hallux-pollux."
The oblique head of the adductor pollicis was transected in its central portion, and the hallux disarticulated through the metatarsal cuneiform joint carrying the remainder of the small muscles of the great toe in the transplant. The flexor hallucis longus and extensor hallucis longus tendons were isolated and cut long. The nerves to the hallux were mobilised proximally to a point where they became one unit in a medial plantar nerve and cut. All other tendons and vessels were cut short. Atraumatic vascular clamps were then placed across the artery and vein and the vessel transected to 1 to 2 cm. from the proximal edge of the transplant (Figs. 2 A, B and 3 A). The donor wound was closed by removing the prominence of the cuneiform bone and mobilising dorsal and volar skin flaps. A minute plastic tube was then inserted into the artery of the transplant and 5 ml. Heparin-saline solution (200 U. per ml.) injected (Fig. 2 C).
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