Preoperative evaluation

Proper preoperative planning of great toe-to-thumb transplantation can save hours of operating room time. Evaluation of the residual blood supply to the injured hand can be performed with a pencil Doppler, or in some circumstances may require an angiogram. Crushed or avulsed hands often have vascular anatomy that cannot be fully evaluated by pencil Doppler.

An angiogram of the lower extremity may reveal a dorsal or plantar dominant system of the first dorsal metatarsal artery. In the plantar dominant patient, the major blood supply to the great toe lies volar or plantar to the transverse metatarsal ligament. In dorsal dominant systems, the major blood supply comes from the first dorsal metatarsal artery that lies dorsal to the transverse metatarsal ligament in the first web space. Unfortunately, it is often difficult to obtain high-quality arteriograms of the toes because of vascular spasm problems during the arteriogram procedure. Best results are obtained when the procedure is performed under general anesthesia, which is the method of choice in children.

In the foot, a strong Doppler signal that persists down through the first intermetatarsal space to the first web space usually indicates a dorsal dominant system with a superficial first dorsal metatarsal artery arising from the dorsalis pedis. If the signal is lost at the proximal portion of the first web space at the base of the first and second metatarsals, then the surgeon can presume that the major arterial blood supply to the toe comes from the deep plantar system. We have found that the Doppler signal correlates with the arteriogram and operative findings in nearly 100% of the cases [13].

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