Left Great Toe to Right Thumb 24 yo M s/p failed replantation of crush avulsion injury to right thumb 1 Incision for the toe is designed around the 1st MC head with plantar and dorsal skin flaps The incision is extended dorsally and plantarly to allow dissection of the first dorsal metatarsal artery and flexor tendons and nerves respectively. 2 The toe can be trimmed on the medial surface if desired, or harvested intact. Care should be taken to gently handle and preserve the medial skin flap as it can be prone to necrosis from tight skin closure. 3 Osteosynthesis to the remnant proximal phalanx can be achieved with k-wires +/- interosseous wires, screws or plates. The base of the toe proximal phalanx was hollowed out with a burr to allow intussusception. 4 After skeletal fixation, the tendons are attached, followed by the artery. The princeps pollicis is a satisfactory size match, or end to side into the radial artery is also possible. Generous skin flaps created at the time of the initial traumatic coverage aid in closure around the base of the thumb. Care should be taken to position the thumb in pronation and abduction 5 6 Great toe to right thumb 14 yo M 5 months s/p fireworks injury to right hand 2nd toe transfer to right thumb 7 Injury 8 • The first dorsal metatarsal artery can be used to harvest the first or Extensor tendon second toe. Careful dissection may also facilitate harvest of an additional dorsal First dorsal metatarsal vein to augment artery & vein Saphenous vein venous drainage. • The vascular anatomy of the first dorsal metatarsal artery may be variable, with either dorsal or plantar systems dominating 9 • If the arterial system is found to be dorsal, the plantar dissection Flexor tendon may proceed quickly. Care should be taken however to identify and protect the digital nerves, which should be harvested with as much length as possible to minimize the need for an interpositional graft. 10 First dorsal metatarsal artery & vein Extensor tendon Digital nerves Flexor tendon 11 12 13 6 weeks post-op 14.