Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al. |
C. The dissection has now been carried distally to the first web space,
where the communications between the first metatarsal artery and the deeper
plantar arterial system are shown crossing the distal free edge of the transverse
metatarsal ligament. The proximal communicating vein and artery at the base
of the first web space have been tied, releasing the two vessels distally
into the transplant. Branches entering the second toe in the web space from
the now common dorsal and volar systems must be tied. Had the first metatarsal
artery not been a large, usable structure, the arterial dissection would
then have proceeded deep to the transverse metatarsal ligament, severing
the ligament to facilitate exposure. This dissection would have been carried
back in the first metatarsal space for 3 to 4 cm to provide an adequate
vessel pedicle. The artery usually runs on the lateral side of the lateral
sesamoid bone and can be delivered, if needed, with difficulty to obtain
a longer pedicle. The digital nerve to the lateral side of the great toes
runs with these plantar vessels, usually on their plantar lateral side.
The nerves are large and can often be identified before the vessels and
followed proximally to locate the vessels. One can intentionally begin the
dissection on the second toe, isolating the digital nerve to the medial
side of the second toe and tracing it proximally to where it joins the common
plantar digital nerve to the large toe. These nerves can be split from one
another to create a long proximal pedicle of several centimeters, limited
only by the extent of the dissection on the sole of the foot. A longitudinal
incision between the first and second metatarsal heads in the sole of the
foot is seldom symptomatic and greatly facilitates this neurovascular pedicle
dissection.
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PLATE I-3
A. The incision has been carried down the medial side of the triangular flap at the base of the toe, carefully mobilizing the venous pedicle into the transplant. The long flexor tendon has been mobilized in this dissection, and the medial digital nerve to the toe has been isolated. This nerve lies directly on the metatarsal joint capsule and may be accompanied by a sizable medial digital vessel. The long flexor tendon and medial digital nerves have now been isolated and retracted.
A. The toe is now angulated medially and the joint capsule incised, disarticulating the toe through the metatarsal joint. If one is going to reconstruct a metacarpal joint, a large cuff of this metatarsal joint can be carried with the toe transplant. The long flexor tendon must be retracted distally so that it is not injured during this disarticulation. The sesamoids on the volar surface of the metatarsal head tend to slide proximally as this joint capsule is transected. |
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