|| Great-toe transplant was performed to a severely mutilated hand with only a single shortened ulnar digit remaining.
FIG. 1-55. The proximal third of the first metacarpal is present. There is considerable scarring in the remaining radial portion of the hand, which may require subsequent resurfacing with a conventional or microvascular transplant.
FIG. 1-56. Dorsal view shows good skin cover. There is a nubbin of the proximal phalanx of the ring finger that could serve as a base for a subsequent second-toe transplant to provide three-finger pinch.
FIG. 1-57. Potential mobility of the residual hand: the thenar muscles have good mobility, the remaining first metacarpal rotates well, and the remaining proximal phalanx of the fifth finger flexes to 90 degrees. There are good flexion and extension of the residual proximal phalanx of the ring finger also.
FIG. 1-58. X ray of the hand shows the residual stumps of the first metacarpal of the proximal phalanx of the ring finger and the entire proximal phalanx of the little finger. The second metacarpal is missing, which helps to increase the web space between the contemplated toe transplant and the residual portion of the hand.
FIG. 1-59. Clay model of the proposed toe transplant. Placing this on the hand permits one to visualize the amount of skin needed and the potential length of the transplant. Had this patient had full-length digits remaining on the hand, the shortened metacarpal may have resulted in a thumb that was too short. The remaining digits, however, are short, and the short thumb in this instance matches well with the remaining hand.
FIG. 1-60. The toe has been completely dissected and all structures have been tagged, ready for transfer to the hand. Again, the dorsal and medial aspects of the first metatarsal head arc removed to permit closure of the foot wound, preserving the weight-bearing surface of the volar surface of the first metatarsal. One can actually transplant the first metatarsal joint, leaving the volar half of the metatarsal shaft and condyles as weight-bearing surfaces, taking the dorsal half of the metatarsal shaft and the dorsal two-thirds of the articular surface to form the metacarpal joint in the hand.
FIG. 1-61. Large-toe transplant in place, showing a hand with good two-finger pinch and with the capability of fairly large tubular grasp. A fair amount of padding has been taken from the volar surface of the great toe, providing durable tissue in the base of the large web space on the hand. This web space still contains indurated unstable scar, which may need resurfacing.
FIG. 1-62. Pulp-to-pulp pinch between the thumb and the residual portion of the little finger is possible and improving. This could be converted to a three-finger chuck type of pinch with a subsequent second-toe transplant to the proximal phalangeal stump of the ring finger.