Invited discussion: Transfer of the second to the first metatarsal ray in a case of lawn mower injury: A case report

Abstract

a redistribution of load across the foot after great toe harvest 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 distributed 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. However, little morbidity was associated with the changes in load distribution. No patient experienced difficulty running long distances and no patient developed an ulceration 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 harvest. 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 transposition. This is an elegant and useful technique for treating chronic ulcerations of plantar surface of the foot. I look forward to utilizing it in my practice.