CASE 4

A great toe was transplanted to a four-fingered hand with an amputation through the metacarpophalangeal joint and loss of the articular surface of the metacarpal.

FIG. 1-26. The condition of the hand after primary injury. The thumb was not replantable because of the crushing nature of the injury and extensive trauma to the amputated part.

FIG. 1-27. The condition of the hand several weeks after the accident. All the wounds have healed, and the toe transplant is scheduled.

FIG. 1-28. The toe has been transplanted to the thumb position with a fusion at the metacarpophalangeal joint. Not a great deal of flexion and extension exist at the distal joint of this thumb. This could probably be improved with tenolysis. Relatively little tissue needed to be carried with the toe.

FIG. 1-29. Opposition of the toe transplant to the middle phalanx of the little finger. There are good thenar muscle activity, rotation of the first metacarpal, and movement at the basilar joint of the thumb.

FIG. 1-30. Strong tubular grasp has been restored to this hand with the powerful great-toe transplant.

FIG. 1-31. Closure of the donor wound on the foot was without tension, and there is good padding over the metatarsal head.

CASE 5

A high school student had a large toe transplanted to a four- fingered hand after a water-skiing accident.

FIG. 1-32. Avulsive amputation through the base of the proximal phalanx of the thumb.

FIG. 1-33. Results after transplantation of the great toe, using the remaining base of the proximal phalanx as an intramedullary pin into the proximal phalanx of the toe. The transplanted toe and the opposite thumb are of equal length. The bony architecture and nail breadth are wider on the transplanted toe, but this discrepancy seems to decrease with time and is seldom noticed by the critical observer except when the thumb and the transplanted toe are placed side by side.

FIG. 1-34. X rays show that the proximal phalanx is used as an intramedullary peg into the base of the proximal phalanx of the toe, which gives tremendous bony contact, rapid healing, and excellent opposition.

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