INVITED DISCUSSION: TRANSFER OF THE SECOND TOTHE FIRST METATARSAL RAY IN A CASE OF LAWNMOWER INJURY: A CASE REPORT

DARRELL BROOKS, M.D.*

The authors present a case report involving second toe

transposition onto the first toe at the level of the metatar-

sal neck to treat chronic pressure ulceration under the

first metatarsal head. The authors believe the ulceration

was due to changes in the first ray/longitudinal arch

architecture stemming from loss of the great toe. They

cite studies of Poppen et al.1 and Mann et al.2 who found

a redistribution of load across the foot after great toe har-

vest for hand reconstruction. Suggested refinement to the

technique of great toe harvest included maintaining the

base of the proximal phalanx and its associated insertions

to decrease loss of arch height. This became the author’s

rationale for second toe transposition onto the first ray.

The studies of Mann and Poppen showed a common

load shift from the first metatarsal head to the second

and third metatarsal heads with more weight being dis-

tributed to the lateral aspects of the foot. Based on this

lateral shift, if there were to be an area at risk for

increased pressure and ulceration, it would be under the

second or third metatarsal head. The first metatarsal head

would be relatively protected. There were functional

changes noted in some of the patients including weakness

in push-off and cutting maneuvers related to sports. How-

ever, little morbidity was associated with the changes in

load distribution. No patient experienced difficulty run-

ning long distances and no patient developed an ulcera-

tion of any kind.

I am not sure that the situation described in this case

(i.e., severe multilevel trauma of the soft tissue envelope

around the metatarsal head) is analogous to great toe har-

vest. The ulceration in this case report could be related

to the extent of the soft tissue trauma. Figure 1 in the

case report illustrates an amputation of the great toe at

the base of the proximal phalanx with a second level soft

tissue injury described by the authors as, ‘‘circumferential

avulsion of the soft tissue around the MP joint.’’ It is not

difficult to imagine that the distal branches of the medial

plantar nerve would be involved resulting in insensate

native skin under the metatarsal head. Subsequent soft

tissue reconstruction of the dorso-medial aspect of the

foot was also insensate. The fact that the ulceration

developed 10 years after the injury leads this reader to

believe that an insensate, traumatized soft tissue envelope

was more responsible than redistribution of the foot load.

The authors do accomplish stable (5 year follow-up)

reconstruction of the plantar aspect of this traumatized

foot with what I presume was a sensate second toe trans-

position. This is an elegant and useful technique for treat-

ing chronic ulcerations of plantar surface of the foot. I

look forward to utilizing it in my practice.

REFERENCES

1. Poppen NK, Norris TR, Buncke HJ. Evaluation of sensibility andfunction with microsurgical free tissue transfer of the great toe to thehand for thumb reconstruction. J Hand Surg 1983;8:516–531.

2. Mann RA, Poppen NK, O’Konski M. Amputation of the great toe.Foot Ankle 1981;226:192–205.

Buncke Clinic, California Pacific Medical Center, San Francisco, California

*Correspondence to: Darrell Brooks, M.D., Buncke Clinic, California PacificMedical Center, San Francisco, California. E-mail: darrellbrooks@usa.net

Received 16 September 2008; Accepted 7 October 2008

Published online 12 February 2009 in Wiley InterScience (www.interscience.wiley.com). DOI 10.1002/micr.20596

VVC 2009 Wiley-Liss, Inc.