Surgery Spotlight: Combined Second and Third Toe Harvest and Transfer for Hand Reconstruction-Surgery Spotlight: Combined Second and Third Toe Harvest and Transfer for Hand Reconstruction

Surgery Spotlight: Combined Second and Third Toe Harvest and Transfer for Hand Reconstruction

Video Transcription

This video demonstrates the harvest of a combined second and third toe transfer. This has a single vascular pedicle, indications are missing two adjacent fingers, not proximal  to the web space, remaining finger not longer than the little finger. As a single microsurgical procedure, less operative time, lesser donor site dissection,  less recipient site dissection, and the results are comparable.  This demonstrates normal motion in the toes. The first dorsal metatarsal artery is marked along its course between the first and second metatarsal bones.  Bifurcation of this artery into the first and second toe proper digital artery is marked. The foot is placed in a dependent position and the dorsal veins going to the second and  third toes are marked. It will all join to drain into one sizable superficial vein. We only need one vein for this flap.  The midpoint of the web space is marked with black ink both in the first and third spaces.  The tip of the V-shaped wedge is decided upon based on the position of the bone cut required.  The tip should be one to two centimeters proximal to the position of the bone cut or the joint disarticulation.  Usually, we mark the tip at least two centimeters proximal to the web space. The plantar incisions fall in the plantar grooves.  The same principle applies to both the dorsal and plantar incisions. The amount of skin required at the recipient site and the position of the bone cut both  determine the exact placement of the skin incisions. The first, second, and third plantar digital arteries are marked. The dorsal incision is made in the first web space.  We prefer to locate and isolate the first dorsal metatarsal artery in the superficial vein first. The superficial vein is visualized here. Branches to the first toe are clipped.  By clipping the branches to the first toe and retracting the vein towards the second toe, the dissection becomes easier.  The dissection is continued in the web space until the artery is visualized.  The dissection continues in the web space here, and the plantar incision is made.  This dissection continues until the artery is visualized.  We look for the proper digital artery to the great toe and the second toe.  Here you can see it. It appears that the plantar metatarsal artery is large.  The vessel travels below the transmetatarsal ligament and therefore it is part of the plantar system.  We'll show later that this is not the case and the dominant system is actually the dorsal one, not the plantar one in this case.  Note the thickness of the fibro-fatty tissue of the plantar aspect of the foot.  One can also visualize a branch to the joint. That's a branch that we ligate that can be used to transfer a vascularized joint if necessary.  Green red arrows mark the arteries of the plantar system. The yellow arrow marks the branches of the deep perineal mirror providing sensation to the web space.  The nerves are always found in the 4 and 8 o'clock position with the center of the clock being the toe itself.  The second incision is made and the wedge-shaped flap is raised as a skin flap only, leaving  the fibro-fatty tissue of the plantar foot in place. This will decrease the bulkiness during the inset and possibly allow for more mobility  of the newly transferred metatarsopharyngeal joint.  We have not had problems with the protrusion of the skin flap.  Now we look for the common digital artery and nerve.  Here you can see the common second metatarsal artery.  Arrows mark the proper digital artery to the second toe, the common digital artery to the second and third toes. Also, you can see the third common digital nerve  with its branch to the third toe.  The flexure tendon sheath is visualized and open.  The length of the tendon needed is dependent partly on the requirement at the recipient site.  Here you can see the dissection of the superficial vein approximately on the dorsal side. It's divided to a point where enough length is achieved.  You can see the superficial perineal nerve is divided also and marked with a 6-zone outline suture.  The nerve to the lateral side of the second toe is also identified, transected, and marked.  Here you can see the proper digital nerve to the medial side of the second toe, the common digital nerve to the second toe and third toe, and the proper digital nerve to  the third toe on the lateral side.  This is the plantar  metatarsal artery.  The communication of the first torso metatarsal artery with the plantar system. Here's the branch to the right toe is clipped and ligated.  Ligated and cut.  Now the first torso metatarsal artery with its branch to the second toe is isolated.  Here the flexor tendons are isolated and cut at a point where adequate length  is achieved.  Plantar arteries and digital nerves are marked, identified. Back to the dorsal aspect of the foot, the extensor tendon is identified and dissected.  The tendon is cut at the nerve dorsally and the nerve dorsally is cut.  The vein is divided and all structures are elevated distally, and the metatarsopharyngeal joints are exposed.  The soft tissue is dissected in a subperiosteoplane 3 or 4 mm distally in order to provide a place for wire fixation.  The soft tissue in the web spaces is not disturbed since a larger portion of the blood supply to the toes is communicated through vessels in the soft tissue.  The volar plate and joint capsules are cut. At this point only the first dorsal metatarsal artery is still in continuity.  Although we don't let the tourniquet down in this particular case, we do recommend doing so at this stage to re-establish blood flow and to assure good circulation in the toes  after the harvest. On the back table preparation of the toes is performed. It's very critical to pay special attention not to injure any of the important structures  while exposing the bones and drilling the holes necessary for fixation.  A towel clamp is used to manipulate the phalanx.  A periosteal dissection is performed. The flexor tendon pulley is preserved when possible. This depends on the level of amputation.  Drill holes are placed before resection of the joint cartilage.  Parallel holes are used instead of 90-90 degrees because this allows for a stable fixation that can still be adjusted slightly during the initial clinical visits if necessary.  After proper fixation, the digit can then be splinted.  Here we see an x-ray of the hand. This patient has metacarpal hand type 1. All digits are amputated at the base of the proximal phalanx level with the MCP joints intact.  The thumb is present and functional, but for this case, we do not need the metatarsophalangeal joints and the transplanted toe will not have this joint.  Previously, to augment the soft tissue in the hand, this patient had a groin flap transfer.  The second and third toes will be transplanted to the third and fourth fingers in order to restore fingers for thumb opposition to restore a more powerful grip.  The incision was made in a transverse fashion. The proper digital artery is identified. You can also see the branch of the second finger.  The proper digital nerve is also seen at this level. Moving the digital nerve to the second or third finger as a recipient nerve is acceptable  to restore sensation to the transplanted toe. We prefer to reconstruct three nerves to restore sensation to both aspects of the digits, radial  and ulnar, and also to restore sensation to the dorsal aspect of the finger.  In this case, the flexor digitorum shallus and profundus are identified, routinely preserve the A1 pulley when present, or preserve the soft tissue around the tendon that acts as  a pulley in case.  Here you can see the flexure, digitorum profundus and superficialis.  haircut in preparation for receiving the flap.  Real holes are made in the recipient phalanx.  Some of the soft tissue is removed to allow for an easier inset.  A separate incision is made for the recipient vein, as seen here.  Bone fixation is performed using two wires. Be careful not to injure the soft tissue when twisting the wires.  A midline incision is made through the extensor tendon and tendon suturing is performed with all joints in an extended position.  The flexors of the toe are massed most to the flexors of the finger.  The hand should be in a natural position. Two core sutures and a running epitendinous suture are used.  Here you can see the nerves, that will be an estimose.  The skin is trimmed and the inset is completed. Arctobacillus anastomosis.  Prior to performing this inset, the medical is passed to the previously made incision in the web space.  The left box.  The pin is placed through the PIT and DIT and left in place for two weeks.  The pin is then advanced at two weeks in order to exclude the PIT joint and allow for motion in that joint.  The pin is completely removed at one month. Test on asthmosis is performed at this stage.  Incisions are closed without tension.  For this flap, we generally use one artery, the first dorsal metatarsal artery,  and we preserve the other arteries in case there are problems with perfusion.  And one vein is in asthmosis as well.

Video Summary

The video details a surgical procedure involving the simultaneous transfer of the second and third toes, which share a single vascular pedicle, to replace missing fingers. Ideal candidates for this procedure are those with two adjacent missing fingers that are not located proximally to the web space, with at least one remaining finger not longer than the little finger. The surgery is streamlined, requiring less time and dissection at donor and recipient sites, with outcomes comparable to traditional digit transfers. The process involves meticulous identification of vascular and nerve structures, crucial for ensuring proper blood flow and sensation post-transplant. The dorsal and plantar incisions are carefully planned to enable effective skin flap and joint transfer. Bone fixation is done using parallel drill holes for stability, allowing some postoperative adjustment. The toes, once fixed, are transferred to restore opposition and grip, with careful consideration of nerve anastomosis to regain sensation.

Asset Caption

This video demonstrates a "Combined Second and Third Toe Harvest and Transfer for Hand Reconstruction." Surgeon Fu Chan Wei, MD and Wee Leon Lam, MD

Source

Neligan, P. C. (Ed.). (2012). Plastic Surgery: 6-Volume, 3^rd Edition. Philadelphia: Saunders.

Disclosure This material is presented thanks to a generous licensing grant from Elsevier, and is taken from Plastic Surgery: 6-Volume Set, 3rd Edition edited by Peter C. Neligan, MD. "Combined Second and Third Toe Harvest and Transfer for Hand Reconstruction" appears in Volume 6: Microsurgical Techniques.

This product is not certified for CME.

Keywords

surgery spotlight

Surgical Videos

Hand

Nerve

Fu Chan Wei MD

Wee Leon Lam MD; Memben

toe transfer

vascular pedicle

missing fingers

nerve anastomosis

bone fixation

surgical procedure