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narrowed and the missing toe is seldom noticed.
Operative Sequence
PLATE III-1
A. The dorsal skin incisions are made first.
B. The dorsal triangular flap can be moderately long. Closure of the
foot wound is greatly simplified by removing the second metatarsal. Similarly,
the plantar flap extends proximally beyond the metatarsal head.
C. Just beneath the dermis, the dorsal veins are located and isolated.
The skin incision is extended proximally, overlying the course of the
dorsalis pedis vessels. Through this incision, the superficial veins can
be followed proximally and medially to allow sufficient length for anastomosis
to the veins in the hand in an area where the veins are free of scar tissue.
D. The extensor hallucis brevis tendon is identified and divided near
the extensor hallucis longus tendon. Just deep to the extensor hallucis
brevis tendon, the dorsalis pedis artery and its venae comitantes are
found. At this level, the artery is on the tarsal bones (primarily the
first cuneiform).
E. As the artery passes distally over the proximal portion of the
first web space, it gives off the first dorsal metatarsal artery, and
often an artery contributing to the dorsal arch, before diving between
the heads of the first dorsal interosseous muscle to contribute to the
plantar circulation. The first dorsal metatarsal artery is followed distally
as it passes either superficial to or just deep to the fascia overlying
the first dorsal interosseous muscle. Occasionally, it is found deeper
in the substance of the muscles in the first web space. The artery is
often not present at all, and in our experience, in approximately 60%
of cases, the transfer must rely entirely on identification and use of
the plantar vessels.
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If the first dorsal metatarsal artery is present, it is followed distally to its communication with the plantar circulation, with care taken to dissect only the medial aspect of this vessel.
F. The branch of the first dorsal metatarsal artery to the great toe
is ligated and divided, as shown in this illustration. The incision is
then continued into the web space and onto the plantar aspect of the foot.
The neurovascular bundle on the lateral aspect of the great toe is then
isolated and followed proximally, to locate the neurovascular bundle of
the second toe. The common digital nerve to the first web space must be
split to increase the length of digital nerve attached to the toe. The
plantar digital artery to the great toe is ligated and the common digital
artery is dissected proximally to increase the length of the plantar arterial
pedicle (particularly if the toe is to rely on the plantar circulation).
The transverse metatarsal ligament is then incised to free the head of
the second metatarsal medially and facilitate the proximal dissection.
PLATE III-2
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