FIG. 28-26. Reconstruction was begun on the left hand by restoring grasp with the simultaneous transplantation of three toes. The second and third toes from the right foot were transplanted to the ulnar aspect of the hand, and revascularized by end-to-end anastomosis to a dorsal radial artery side branch. The ipsilateral second toe was then transplanted to the radial side of the hand, fixed in place by reconstruction of the remnant metacarpophalangeal capsule, and revascularized through a second dorsal radial artery branch. Nine toe digital nerves were anastomosed to remnant nerve stumps in the hand.

FIG. 28-27. Three months after reconstruction. The patient underwent physical therapy to improve motion to the toes, and had protective sensation to the digits and three-finger pulp-to-pulp pinch.

FIG. 28-28. At 8 months, a third toe was transplanted to the right hand to lengthen the thumb stump.

FIG. 28-29. Third-stage reconstruction was performed to the left hand to widen the web space, using a lateral arm flap, combined with rotational osteotomy of the ulnar digit. Arm flap next to hand.

FIG. 28-31. Postoperative view following the successful fourth microvascular transplant. The patient is now independent, and wears normal shoes with no ambulatory problems.

FIG. 28-32. Patient holds coffee pot and cup with reconstructed digits.

CASE 6

A 26-year-old man suffered a crush injury in a logging accident that resulted in amputation of all fingers except the small finger.

FIG. 28-33. Preoperative view one year following initial injury. The thenar eminence is covered with stable skin grafts, but there is inadequate soft tissue to support a great toe transfer. The carpometacarpal joint is present. The dorsum of the hand was covered with a pedicled groin flap.

FIG. 28-34. Dissection was begun through the edge of the groin flap, exposing the remnant thenar base median nerve and radial vessels. Reconstruction was performed with simultaneous transplantation of a great toe and a serratus muscle, to provide pinch and an adequate web space. The dorsal metatarsal artery was anastomosed end-to-side to the dorsal radial artery. The serratus muscle was wrapped around the base of the toe transplant and revascularized end-to-end to the distal dorsal radial artery. All venous outflow was through vena comitantes. Digital nerves of the toes were repaired to the median nerve.

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