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Short reports and correspondence| Volume 56, ISSUE 3, P309-310, April 2003

Replantation of the great toe in a woman

      Sir,
      Unlike replantation of digits and the increasing number of toe-to-hand transplantations, the replantation of toes does not seem to be frequently performed.
      • Werber K.D.
      • Biemer E.
      • Glas K.
      Replantation of the hallux by microsurgical techniques.
      • Inoue T.
      Report of the toe replantation.
      • Muramatsu K.
      Toe replantation.
      • Sakamoto K.
      • Kozuki K.
      • Maki H.
      Replantation of the great toe: two case reports.
      • Ademoğlu Y.
      • Ada S.
      • Kaplan I.
      Should the amputations of the great toe be replanted?.
      • Sabapathy R.
      • Mohan D.
      • Singh S.B.
      • Venkatramani H.
      Replantation of great and second toes: a worthwhile effort.
      Moreover, the success rate of toe replantation is low,
      • Werber K.D.
      • Biemer E.
      • Glas K.
      Replantation of the hallux by microsurgical techniques.
      • Ademoğlu Y.
      • Ada S.
      • Kaplan I.
      Should the amputations of the great toe be replanted?.
      because the vessels are small in calibre, the interdigital space is small for arterial anastomosis and the reduced mobility of the vessel stumps makes anastomosis tedious.
      • Inoue T.
      Report of the toe replantation.
      I successfully replanted the great toe in a 25-year-old woman (Fig. 1) . In the first web space of the stump, the first lateral plantar digital artery (FLPDA) was chosen for arterial supply. To place the end of this artery in the most superficial location, the anterior perforating artery was ligated and divided. In the medial stump, the first medial plantar digital artery (FMPDA) and the medial plantar artery (MPA) were exposed as distally and proximally as possible so that the stump of the artery could be anastomosed in the superficial plane. Two subcutaneous veins were isolated for venous drainage. In the amputated toe, the FLPDA and the FMPDA were exposed distally into the fatty tissue until they could be mobilised and placed superficially. Two subcutaneous veins were detected at the base of the nail matrix. The amputated toe was transfixed to the proximal stump through the metatarsophalangeal joint with a Kirschner wire, allowing a slight flexion of the interphalangeal joint. The ends of the flexor hallucis longus tendon were attached, and the extensor hallucis longus tendon of the amputated part was tied to the intact extensor hallucis brevis tendon in the proximal stump. While maintaining the widest possible interdigital space using a retractor, the lateral digital nerve was repaired. The FLPDA of the amputated toe was anastomosed to the FLPDA of the stump using an interpositional vein graft (1 and 2 in Fig. 2) . For venous drainage, one of the subcutaneous veins of the amputated toe was anastomosed to one of the ends of the net-like vein graft. One of the ends of the net-like vein graft on the other side was sutured to one of the subcutaneous veins in the proximal stump. The flow of blood into the replanted great toe was confirmed and then the medial digital nerve in the medial portion of the great toe was repaired. The FMPDA and the MPA were anastomosed using an interpositional vein graft. Finally, on the dorsum of the great toe, the remaining subcutaneous veins were anastomosed.
      Figure thumbnail gr1
      Figure 1A 25-year-old woman with a crush injury to the dorsum of the right foot and a complete amputation of the right great toe.
      Figure thumbnail gr2
      Figure 2Schema of the arterial procedures in the web space. FDMA, first dorsal metatarsal artery; FPMA, first plantar metatarsal artery; FLDDA, first lateral dorsal digital artery; FLPDA, first lateral plantar digital artery; IL, intermetatarsal ligament; VG, interpositional vein graft. Numbers indicate the order in which the vessels were anastomosed.
      The replanted toe healed well. The interphalangeal joint regained only 20° of flexion owing to adhesions; however, the active metatarsophalangeal joint motion was 40°. The static two-point discrimination on each side of the toe pulp was 15 mm, and the moving two-point discrimination was 13 mm. The patient was very satisfied with the appearance and function of the replanted great toe (Fig. 3) .
      Figure thumbnail gr3
      Figure 3Postoperative appearance at 16 months.
      Yours faithfully,

      References

        • Werber K.D.
        • Biemer E.
        • Glas K.
        Replantation of the hallux by microsurgical techniques.
        Arch Orthop Trauma Surg. 1982; 100: 127-129
        • Inoue T.
        Report of the toe replantation.
        J Jpn Soc Reconstr Microsurg. 1990; 3 (in Japanese): 300-302
        • Muramatsu K.
        Toe replantation.
        Orthop Surg Trauma. 1995; 38 (in Japanese): 863-867
        • Sakamoto K.
        • Kozuki K.
        • Maki H.
        Replantation of the great toe: two case reports.
        Foot Ankle Int. 1998; 19: 638-640
        • Ademoğlu Y.
        • Ada S.
        • Kaplan I.
        Should the amputations of the great toe be replanted?.
        Foot Ankle Int. 2000; 21: 673-679
        • Sabapathy R.
        • Mohan D.
        • Singh S.B.
        • Venkatramani H.
        Replantation of great and second toes: a worthwhile effort.
        Plast Reconstr Surg. 2000; 106: 229-230