Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 1:
Great Toe Transplantation

B. All structures except the vascular pedicles have been divided. At this point, the tourniquet is released and bleeders are clamped and ligated, with particular attention paid to the branches entering the arterial pedicle.


A. Microvascular clamps have been placed on the dorsalis pedis artery and vein and the vessels tied proximally, freeing the toe from the foot and preserving as long a pedicle as needed.


A. The volar dissection is depicted on the hand, exposing the median nerve and its branches to the amputation stump of the thumb. The flexor pollicis longus is caught in the scar tissue at the base of the metacarpal, which will be used as a bonepeg into the base of the proximal phalanx of the toe.

B. The transplant has been fixed in a position of opposition withan intramedullary pin. A fine screw can be used transversely, crossing all four cortices. The dorsalis pedis artery has been anastomosed end to end in the dorsal radial artery. The deep peroneal nerve has been anastomosed to a branch of the superficial radial nerve and the saphenous vein has been repaired in end-to-end fashion to the cephalic vein.

  C. A dorsal overview, with the extensor pollicis longus and the extensor hallucis longus sutured in a fish mouth fashion.

D. The flexor hallucis longus has been anastomosed to the flexor pollicis longus in the wrist, proximal to the flexor crease. The digital nerves from the toe have been anastomosed to the digital nerves to the thumb.


The following clinical cases illustrate the use of the great-toe transplant to restore function to mutilated or minimally injured hands. The first goal is to restore key pinch, then pulp-to-pulp pinch, followed by chuck pinch and finally grasp. The reconstructive plan depends on what is missing and what is available and how much the patient is willing to give up. Some patients are unwilling to accept a transplant of the toe or even a portion of the toe because they feel that it further destroys their "body image." Others accept the concept, readily realizing that the function of the hand will be improved and, in addition, all or part of the deformity and disability will be transferred to the foot, where it is better tolerated and less obvious. The hands and face are still the most exposed parts of the anatomy in present society.


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