Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 1:
Great Toe Transplantation
  C. The dissection has now been carried distally to the first web space, where the communications between the first metatarsal artery and the deeper plantar arterial system are shown crossing the distal free edge of the transverse metatarsal ligament. The proximal communicating vein and artery at the base of the first web space have been tied, releasing the two vessels distally into the transplant. Branches entering the second toe in the web space from the now common dorsal and volar systems must be tied. Had the first metatarsal artery not been a large, usable structure, the arterial dissection would then have proceeded deep to the transverse metatarsal ligament, severing the ligament to facilitate exposure. This dissection would have been carried back in the first metatarsal space for 3 to 4 cm to provide an adequate vessel pedicle. The artery usually runs on the lateral side of the lateral sesamoid bone and can be delivered, if needed, with difficulty to obtain a longer pedicle. The digital nerve to the lateral side of the great toes runs with these plantar vessels, usually on their plantar lateral side. The nerves are large and can often be identified before the vessels and followed proximally to locate the vessels. One can intentionally begin the dissection on the second toe, isolating the digital nerve to the medial side of the second toe and tracing it proximally to where it joins the common plantar digital nerve to the large toe. These nerves can be split from one another to create a long proximal pedicle of several centimeters, limited only by the extent of the dissection on the sole of the foot. A longitudinal incision between the first and second metatarsal heads in the sole of the foot is seldom symptomatic and greatly facilitates this neurovascular pedicle dissection.


A. The incision has been carried down the medial side of the triangular flap at the base of the toe, carefully mobilizing the venous pedicle into the transplant. The long flexor tendon has been mobilized in this dissection, and the medial digital nerve to the toe has been isolated. This nerve lies directly on the metatarsal joint capsule and may be accompanied by a sizable medial digital vessel. The long flexor tendon and medial digital nerves have now been isolated and retracted.

B. On the dorsum, the long extensor has been transected, and the dorsalis pedis artery and deep peroneal nerve are held up in a vascular loop. The large saphenous vein coming on the medial side of the transplant is also ready for transection.


A. The toe is now angulated medially and the joint capsule incised, disarticulating the toe through the metatarsal joint. If one is going to reconstruct a metacarpal joint, a large cuff of this metatarsal joint can be carried with the toe transplant. The long flexor tendon must be retracted distally so that it is not injured during this disarticulation. The sesamoids on the volar surface of the metatarsal head tend to slide proximally as this joint capsule is transected.

next page...

  2002 © This page, and all contents, are Copyright by The Buncke Clinic