|| FIG. 1-07. Dorsal view of the toe dissection after the large toe has been dislocated 180 degrees medially. The long flexor is coming off the volar distal aspect of the toe, and the dorsal structures are coming off proximally. Note that a large segment of the metatarsophalangeal joint capsule has been carried with the toe transplant to reconstitute the metacarpophalangeal joint of the thumb.
FIG. 1-08. The great toe has been completely dissected free except for the proximal arterial venous pedicle. The leg tourniquet is removed and the toe perfused in preparation for the transplant.
FIG. 1-09. The completely separated toe transplant with all structures laid out in a spoke-like fashion, starting in a clockwise direction: at I o'clock, the two digital nerves to the large toe, the flexor tendon to the large toe, the dorsalis pedis artery with its continuation as the superficial metatarsal artery, the deep peroneal nerve accompanying the artery, the extensor brevis and longus tendons, and the large dorsal vein, which drained into the saphenous system. The flexor tendon in this case did not have to be long because the thumb flexor was found trapped in scar tissue at the amputation stump.
FIG. 1-10. When the flexor pollicis longus is not at the amputation level, repair is best performed at the wrist level. The flexor hallucis longus can be retrieved in the midplantar area deep to the abductor hallucis.
FIG. 1-11. The flexor hallucis can be cut long at the medial malleolar level, posterior to the posterior tibial neurovascular bundle.
FIG. 1-12. The dissection of the recipient structures in the thumb. The articular surface of the metacarpal head can be seen in the upper portion of the photograph. The dorsal structures are isolated at the level of amputation.
FIG. 1-13. The toe is transplanted when all recipient structures of the hand have been isolated.
FIG. 1-14. The healed toe transplant in position, showing good opposition and pinch between the thumb and little finger.
FIG. 1-15. Flexion at the distal interphalangeal (DIP) joint and metacarpophalangeal joint of the transplanted thumb is present and improving. It is not unusual to get a greater degree of flexion and extension at the DIP joint of the transplanted toe than at that of the remaining opposite toe.
FIG. 1-16. Large tubular grasp and grip have been restored to the hand. The patient returned to playing professional soccer.