Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 1:
Great Toe Transplantation
  Tourniquet time must be carefully monitored and reported to the teams for both extremities on a half-hourly basis by the anesthesiologist or nursing staff. Tourniquet gauges should be checked before each operation. With uncomplicated wound problems in both donor and recipient areas, these dissections should be completed within 1 hour of tourniquet time; however, 2 to 2.5 hours are common to isolate key structures when anomalous anatomic findings are present or the injury is complex. Because the operations are long and the wounds are exposed for several hours, prophylactic systemic antibiotics are given perioperatively before the tourniquets are elevated. All wounds should be periodically moistened. Both teams should keep in constant communication so that the key structures are identified, mobilized, and isolated over sufficient length. The length of each nerve, vessel, and tendon in the donor and recipient areas should be carefully recorded, so that adequate pedicle lengths are carried with the transplant. The team dissecting the hand should measure the required length of each structure from the anticipated osteosynthesis site and record these measurements before any structures are divided in the foot. The need for interpositional grafts of either vessels or nerves should not come as an unpleasant surprise but should be anticipated and planned for if necessary.

Once the dissections have been completed, the tourniquets are removed and hemostasis is obtained in both areas. The vascular supply to the transplant is not clamped or divided until the moment of transfer. If the transplant does not pink up immediately, one must carefully examine the vascular pedicle under magnification. The most common cause of such vascular spasm is an untied arterial branch on the pedicle. Such segmental branch spasm must be corrected by carefully tying the open vessel and treating the pedicle with topical papaverine, 6 mg/cc solution.


Bony stabilization should be carefully planned with the preoperative X rays. Wide bony contact is preferable to ensure early solid union. Such bony contact may be provided by step-cut osteotomies or by the use of a bone peg on the hand fitted into the hollowed-out larger proximal toe phalanx. Increased stability can be gained with a transverse screw through all four cortices. The metacarpophalangeal joint of the thumb should be reconstructed, not only to provide additional motion but to shorten the postoperative immobilization time. Within 3 weeks, active exercises can be instituted and tendon gliding encouraged. With good, solid bony stabilization, active mobilization of the interphalangeal joint can be started early to decrease adhesions.

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