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A. The lateral dissection is then performed, taking care to preserve
any dorsal veins that drain the toe. The lateral neurovascular bundle of
the second toe is isolated and the arterial branch to the third toe ligated
and divided. The transverse intermetatarsal ligament is then divided in
the second web space to further free the second metatarsal and improve access
to the plantar neurovascular bundles.
B. The plantar dissection is completed, preserving the neurovascular
bundles. The flexor digitorum longus and brevis tendons are isolated proximal
to the flexor tendon sheath through the plantar incisions. The length
of flexor tendons retrieved can be increased if necessary by making a
small transverse plantar incision proximally on the sole. Drawing the
flexor tendons from the distal wound is often difficult, owing to the
interconnections between the toe flexor tendons proximally in the foot.
For thumb reconstruction, adequate tendon length is needed so that repair
can be performed proximally to the flexor crease of the wrist.
C. The metatarsal osteotomy is performed at an appropriate level,
which is determined preoperatively by examining the hand and determining
the required length, both clinically and with the aid of radiographs.
More of the metatarsal is taken than needed because it is often telescoped
into the remaining portion of the first metacarpal, or it may receive
a portion of the proximal phalanx in a finger reconstruction. Bone pegs
for intramedullary
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stabilization can also be fashioned from the residual second metatarsal shaft. If there is an adequate first dorsal metatarsal artery, the plantar neurovascular bundles are divided at the proper length and tagged. The only remaining connections to the foot are the saphenous vein, the first dorsalis pedis artery, and the extensor tendon, which acts as a safety leash to prevent tension on the vessels. The tourniquet is then deflated and the toe reperfused for 10 to 15 minutes.
D. Following reperfusion, the vessels are ligated, the extensor tendon
is cut, and the toe is transferred to the hand. The medial aspect of the
toe transplant is shown here. Both flexor and extensor tendons can be
seen. The dorsalis pedis artery, its ligated branch, the first dorsal
metatarsal artery, and its ligated branch to the great toe are illustrated.
The plantar digital neurovascular bundles are also shown.
PLATE III-3
 A.
B.
Closure of the foot is facilitated by removal of most of the second metatarsal.
The remaining cuff of the transverse metatarsal ligament can be sutured
with non-absorbable suture to approximate the first and third metatarsal
heads. Suture closure of the skin is then easily performed. A Penrose
drain is used to drain the wound dorsally for 24 hours postoperatively.
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