On a four-fingered hand, a great-toe transplant was performed to restore a thumb amputated through the metacarpophalangeal joint, with reconstruction of the metacarpophalangeal joint using the articular surface of the proximal end of the proximal phalanx of the great toe.
FIG. 1-01. Preoperative status. Independent loss of the thumb on the nondominant hand is one of the most common types of amputation. The holding or pushing hand is vulnerable to injury by power tools manipulated by the dominant hand.
FIG. 1-02. Loss of the proximal and distal phalanx of the thumb, severely compromising function of the hand. Pulp-to-pulp pinch, key pinch, and chuck pinch are lost. Opposition and grasp are also limited.
FIG. 1-03. Preoperative plan of proposed transplant, using clay models to arrange flaps in the donor toe and recipient radial aspect of the hand. Such planning saves operation time and permits accurate wound closure. Skin grafts are better tolerated on the hand than on the foot, even over microvascular pedicles and anastomoses.
FIG. 1-04. Arteriogram of the foot show a dominant superficial first metatarsal artery continuing after the dorsalis pedis gives the large penetrating branch to the deep arch at the base of the first metatarsal space. Unfortunately, this condition is present in less than 60% of cases, and one must be prepared to use the plantar system, lengthened with vessel grafts if necessary.
FIG. 1-05. Dissection of the dorsal surface of the foot is completed. A large venous pedicle can be seen coming in the medial side of the base of the triangular dorsal flap. A vascular loop is around the dorsalis pedis artery, where it breaks up into the superficial metatarsal artery and the penetrating branch to the deep arch at the base of the first metatarsal space. A branch of the deep peroneal nerve can be seen next to the artery, continuing into the lateral side of the dorsal surface of the toe transplant.
FIG. 1-06. Dissection in the first metatarsal space, looking proximally, after the great toe is partially dislocated medially. The superficial metatarsal artery can be seen in the upper portion of the metatarsal space, and the deep branches from the plantar arterial supply can be seen coming into the base of the toe. The silk tie is on the lateral plantar digital nerve to the great toe. in this instance, the superficial or deep arterial supply could have been used to sustain the transplant,