Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 4:
Vascularized Toe Joint Transplantation
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  When the recipient site is ready, the pedicle is divided at the appropriate length to allow primary anastomosis and the joint brought to the hand. The proximal and middle phalanges of the toe may be tapered or hollowed to act as a male or female connection, depending on the size of the bone ends. This dowel technique provides for a more stable bony fixation when combined with carefully aligned K-wire fixation. Early postoperative movement is then possible and should be instituted. Additional length of each phalanx must be preserved to permit this type of bony fixation. The vascular anastomoses are performed in standard microsurgical fashion, followed by the nerve and tendon repairs when the MT joint is transplanted the flexor digitorum brevis tendon (the sublimis tendon of the toe) is discarded. The flexor digitorum longus the profundus tendon of the toe) is cut long to preserve the vincula blood supply and permit tendon repairs to be performed in the palm proximal to the pulley system and as far distally as possible.

When the PIP joint is transplanted, the long flexor tendon acts as a free graft across the joint because there are few if any vinculae in this area. The short flexor tendon should be cut long proximally, so that it can be repaired to the sublimis in the palm and help to flex the joint.

On the extensor side, the entire mechanism is preserved beneath the cutaneous island carried with the joint. Repairs are made as far distally and proximally as feasible to stagger the level of healing and scar tissue.

 

Wound closure on the hand is accomplished with skin graft if necessary to prevent undue tension of skin flaps or compression of the vascular pedicle. The remnants of the donor toe are resected and the wound closed primarily in layers over a Penrose drain. The donor site generally has an excellent appearance and low morbidity.

Postoperative care and rehabilitation are the same as for a toe transfer.

PLATE IV-1

Vascularized joint transplant.


A. Anatomy of the dorsalis pedis, first dorsal-metatarsal, and digital arteries to the first web and second metatarsal and phalangeal joints of the second toe. Any one of the three joints may be used, depending on the needs of the recipient area.


B. Potential case with loss of the metatarsophalangeal joint of the thumb. Recipient vessels are nearby on the dorsum of the wrist.


C. The metatarsophalangeal joint with an island of overlying skin has been mobilized proximally on the first superficial dorsal metatarsal artery and dorsalis pedis system.

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