Painful Foot Neuromas After Toeto-Thumb Transfer

Christopher T. Maloney, Jr, MD, Ramon DeJesus, MD, Tucson, AZ, A. Lee Dellon, MD, Baltimore, MD

Reconstruction of the thumb by transfer of a toe has evolved technically to the point that this complex procedure can result in a mobile, sensate, and aesthetically pleasing digit that contributes to an almost-normally functioning hand. Donor site deformity is well recognized, primarily as it relates to the appearance of the foot after transfer of the hallux to the thumb position and stiffness of the remaining portions of the big toe. The present report describes donor site disability related to painful neuromas of the supercial and deep peroneal nerves and the common plantar digital nerve to the rst webspace. Salvage of the disabled donor foot is possible by applying techniques used to treat painful neuromas of the upper extremity, neuroma resection, and muscle implantation. The specic techniques used in treating this painful foot donor site after toe-to-thumb transfer are described. (J Hand Surg 2005;30A:105110. Copyright 2005 by the American Society for Surgery of the Hand.) Key words: Toe-to-thumb, toe transplant, painful neuroma.

For more than a quarter century thumb reconstruction by microsurgical transfer of the big toe or second toe has been described and techniques have been rened to the point that a mobile, sensate, and aesthetic thumb can be crafted by the hand surgeon.1 Hand function can be restored to a near-normal degree.2 Using the Lower Extremity Foot Questionnaire Chung and Wei2 found no signicant difference in foot function between thumb amputation patients with and without toe transfers. In those 12 patients studied who had toe transfers to the thumb the big toes were taken at the base of the proximal phalanx to preserve the metatarsophalangeal joint. Four patients
From the Department of Surgery and Orthopedic Surgery, Department of Anatomy, and Department of Surgery, University of Arizona, Tucson, AZ, and Division of Plastic Surgery and Department of Neurosurgery, Johns Hopkins University, Baltimore, MD. Received for publication November 18, 2003; accepted in revised form September 21, 2004. One of the authors (ALD) has a proprietary interest in the Neurotube. Reprint requests: A. Lee Dellon, MD, Ste 370, 3333 N Calvert St, Baltimore, MD, 21218. Copyright 2005 by the American Society for Surgery of the Hand 0363-5023/05/30A01-0016$30.00/0 doi:10.1016/j.jhsa.2004.09.006

had a second toe transfer. When the Lower Extremity Foot Questionnaire results were compared between patients with the big-toe donor site and those with a second-toe donor site a signicant difference was not found (p .484). Patients were are able to ambulate, climb stairs, and participate in sports after toe transfers. The researchers noted that foot donor site complications were minimal. It has been recognized, however, that after transfer of the big toe the foot donor site can have morbidity, which occurs most often when it is necessary to provide skin graft coverage for the big-toe donor site. Gait analysis ndings after toe-to-thumb transfer including forms of the wraparound technique have been reported to be close to normal for the push-off phase of gait as long as the long exor tendon can be preserved. Transfer of pressure to the lateral toes, which may be associated with complaints of foot pain,3 has been documented. In that report hallux rigidus occurred in 38% of patients treated with the wraparound technique. One of the 27 patients in this gait analysis study had a painful neuroma (site not specied) and one had an ulcer (site not specied).3 In contrast, in their review of their 30-year experiThe Journal of Hand Surgery 105

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ence with toe-to-thumb transfer Wei et al1 did not mention foot complications although they noted the following: The donor site management is crucial for overall patient satisfaction. During great toe harvest, it is advisable to preserve at least 1 cm of the proximal phalanx to maintain the foot span, the appearance, and push off function of the donor foot to prevent windlass effect. Skin grafting of the donor site should be avoided in toe transplantation because the graft seldom takes adequately, delays foot function and recovery, and remains as an unstable and painful scar. Other reports of pain related to toe transfer have been rare. For example, 3 of 12 patients were reported to have mild pain after wraparound procedures for thumb reconstruction but a specic cause for this pain such as a neuroma was not given.4 Although Foucher et al5 reported no foot complications after second-toe transfers in children at least 1 other group6 has reported pain: 5 of 11 children had pain in the new intermetatarsal space between the hallux and the third toe and 7 had overt or early hallux valgus. Balance maintenance and rate of displacement of the center of pressure when standing on 1 foot with eyes closed were altered for limbs that had surgery compared with those that did not. Another observation related to foot pain after toe-tothumb transfer is that of phantom toe. This has been reported to have occurred in 13% of a series of 76 toe transfers.7 Finally, in a related type of surgery microvascular toejoint transfer to the hand complications in the foot were noted as follows in the 76 patients in the study8: 1 with rest pain, 6 with pain on movement, 15 with numbness (site not specied), and 5 with a tender plantar scar. Reconstruction of a sensate thumb requires the inclusion of terminal branches of the tibial nerves within the transferred toe, and this creates the possibility for painful neuromas in the plantar digital donor nerves. Additionally, the dorsal foot incision gives the possibility of injuring the deep and the supercial peroneal nerves. The patient presented here sustained severe impairment of the donor foot related to neuromas of the deep and supercial peroneal nerves on the dorsum of the foot and a neuroma of the common plantar digital nerve to the rst webspace. Treatment of these painful neuromas by neuroma resection and muscle implantation permitted salvage of this disabled foot.
Figure 1. Reconstructed thumb showing excellent appearance and range of motion.

Case Report
A 38-year-old, right-handed man sustained an avulsion of his dominant thumb in an industrial accident in March 1999. The avulsed thumb was damaged too badly to permit replantation. After initial wound coverage of the thumb a planned reconstruction with a big-toe transfer was done in March 1999. At that transfer, in addition to the artery, vein, and tendon reconstruction the 2 plantar digital nerves of the big toe were connected to the 2 volar digital nerves of the thumb. The deep and supercial peroneal nerves to the dorsum of the big toe were not reinnervated with the radial sensory nerve branches. The microsurgical transfer was successful and a mobile, aesthetically pleasing thumb was reconstructed (Fig. 1). Unfortunately, despite a well-healed foot donor site the man became disabled because of foot pain. Despite a functioning thumb he was still unable to return to work 3 years after the toe-to-thumb transfer because of inability to ambulate without pain. The pain was both over the dorsal skin surface at the big-toe amputation site and at the region of the rst metatarsal head. His pain level on a visual analog scale level was 10 out of 10, requiring narcotics for analgesic relief. The source of foot pain was localized to painful neuromas of the deep and supercial peroneal nerves and also to the saphenous nerve (Fig. 2). The patients dorsal foot pain required separate local anesthetic block of each of these 3 nerves to relieve the dorsal foot pain. Plantar foot pain remained at the site of resection of the rst metatarsal, requiring an anesthetic block of the common plantar digital nerve

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plantar nerve was identied, divided, and transposed into the arch of the foot (Fig. 4). In the immediate postsurgical period there was no more pain at the metatarsal area with weight bearing and the visual analog scale pain level for this area went from 10 to 0. At 6 months after the second surgical procedure the patient ambulates in normal footwear without pain.
Figure 2. Foot donor site showing cosmetic deformity of the foot and the painful dorsal scar extending from the rst metatarsal head at the end of the amputation to the ankle. The markings on the skin indicate the location of the positive Tinels signs for the deep peroneal nerve (DP), the supercial peroneal nerve (SP), and the saphenous nerve (S).

Discussion
Although the hand surgeon is well versed in the management of painful neuromas of the upper extremity familiarity with techniques to treat these problems in the foot are not well known. When the hand surgeon must use the lower extremity as a donor source for upper extremity reconstruction it is valuable to be aware of techniques to treat painful neuromas in the lower extremity. The case presented in this report shows that the approach to treating the painful neuroma in the upper extremity can be applied successfully to the painful neuroma(s) of the foot. The principles for the treatment of a painful neuroma in the upper extremity involve identication of the source of the pain by anesthetic block of the suspected nerve or nerves and, if nonsurgical measures such as scar massage and desensitization fail to relieve pain, a surgical approach to the painful neuroma.9 This surgical approach includes resection of the painful neuroma, which is the pain-generating source,10 and implantation of the proximal end of the nerve into an area away from tension.11,12 Dorsal foot pain after toe-to-thumb transfer is homologous to dorsoradial wrist/hand pain. Just as more than 1 peripheral nerve must be considered with dorsoradial pain (radial sensory and lateral antebrachial cutaneous nerves)13 so too should more than 1 nerve be considered in the foot. Indeed, in addition to the deep and supercial peroneal nerves the saphenous nerve territory may extend distally and a local anesthetic block of this nerve should be given before the anesthetic is injected to block the peroneal nerve. In the upper extremity it is critical to move the proximal end of the resected nerve(s) away from movement of the wrist. Implantation of the nerves into the brachioradialis muscle has proven a successful solution to this problem.14,15 In the foot translocation of the peroneal nerve(s) into the anterolateral compartment of the foot achieves this same goal.16 Treatment of painful plantar neuromas in the

(Fig. 3). A 2-staged approach was planned for treatment of this painful foot. In the treatment of the painful neuroma it is necessary to interrupt the function of the peripheral nerve that is transmitting the pain impulses. It is not necessary, therefore, to perform surgery on the distal foot and resect the neuromas themselves but rather to divide the indicated nerves at a more proximal level where there is sufcient surrounding muscle bulk in which to implant the proximal end of the divided nerve.9 At the rst surgery a procedure similar to the treatment of dorsoradial wrist pain was planned. Two of the nerves innervating the dorsal foot neuromas, the supercial and deep peroneal nerves, were identied in the anterolateral compartment of the leg. A 2.5-cm segment of the deep peroneal nerve was excised and the proximal end was allowed to remain in its completely muscular environment. The supercial peroneal nerve was divided and its proximal end was turned and implanted deeply into an adjacent muscle. The fascial septum between the anterior and lateral compartments was removed to prevent compression of the implanted supercial peroneal nerve. A fasciotomy of both compartments was done as well. A separate incision was made over the medial lower leg, the saphenous vein was identied, and both the anterior and posterior branches of the saphenous nerve were divided. The proximal end(s) were implanted into the soleus muscle through a fascial window (Fig. 3). In the immediate postsurgical period there was no more dorsal foot pain; the pain level dropped from a presurgical score of 10 on a visual analog scale to a postsurgical score of 0 for the dorsum of the foot. The pain score at the plantar level remained 10. The second surgery used a plantar incision in a nonweight-bearing area through which the medial

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Figure 3. At the rst surgical procedure (A) the supercial peroneal nerve is identied in the anterolateral compartment of the leg. (B) The supercial peroneal nerve is divided distally and the septum between the anterior and lateral compartments is excised (shown lying on skin). (C) The proximal end of the supercial peroneal nerve is implanted into the extensor hallucis longus muscle. (D) The deep peroneal nerve is identied by dissecting along the interosseous membrane medially from the bula to the tibia. A segment of the deep peroneal nerve is excised (shown on the skin overlying the marker) and the proximal end of the nerve is left to lie in the intermuscular plane between the muscles of the anterior compartment.

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Figure 4. At the second surgery the common plantar digital nerve to the rst/second webspace is identied through an incision in the nonweight-bearing portion of the foot. The proximal end of the nerve is implanted into the arch of the foot.

foot is difcult. Reports in the literature are related to treatment of the true neuroma that results after resection of the Mortons neuroma. An approach to treat such a painful recurrent Mortons neuroma was rst reported in 1989 and involved implantation of this nerve into a muscle in the region of the arch of the foot.17 A subsequent series using this approach has been reported recently with a success of 80% excellent and 20% good results.18 If the painful plantar neuroma is the result of injury successful treatment of the pain can be accomplished by reconstructing the defect with a bioabsorbable neural conduit (Neurotube, Synovis Life Technologies, St. Paul, MN).19 After toe-to-thumb reconstruction, however, the distal skin target organ in the footthe toeis absent and so this approach to treatment of the painful neuroma is not applicable. For the patient presented here relocation of the common plantar digital nerve to the rst webspace into the arch of the foot gave sufcient pain relief to permit normal ambulation. The results of successful treatment of this lowerextremity pain problem required application of up-

per-extremity techniques to solve analogous problems in the foot. This approach has proven successful when the technique for treatment of a painful palmar cutaneous neuroma, implantation of the nerve into the pronator quadratus,20 was applied for the treatment of painful neuroma of the medial calcaneal nerve by nerve implantation into the exor hallucis longus muscle.21 The approach to the treatment of the painful posterior saphenous neuroma at the ankle can be used to treat the distal anterior saphenous nerve branch of pain in the toe-to-thumb donor site scar.22 This case report highlights the need for the hand surgeon to have a plan for placing the proximal ends of the divided peroneal and tibial nerve branches such that the risks of painful neuromas can be minimized. For the peroneal nerves it is possible to take sufciently long enough branches of the deep and supercial peroneal nerves that they can be used to connect to the radial sensory nerve and add these nerves for neurotization of the transferred toe. The proximal end of these nerves can be left deep to the extensor digitorum brevis muscle or turned to be implanted into the intrinsic muscles by placing them into this location through the intermetatarsal spaces. The proximal end of the common plantar digital nerve to the rst webspace should be cut sufciently proximal so that it lies within the intrinsic muscles. The postsurgical care of this donor site is important and the program suggested by Wei et al1 should be noted: The donor foot is gently covered with nitrofurazone gauze over the wound and a light uff dressing. No splints are used in the donor foot or the recipient hand. The foot can be uncovered in 2 days without further dressings. The patient is allowed to walk a few steps on the heel of the donor foot after the second week. It is emphasized that any contact with the anterior plantar weight-bearing surface should be avoided during this time. After approximately 6 weeks, the patient is allowed to walk in shoes with a normal gait if the wound is healed.

References
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The Journal of Hand Surgery / Vol. 30A No. 1 January 2005 14. Dellon AL, Mackinnon SE. Treatment of the painful neuroma by neuroma resection and muscle implantation. Plast Reconstr Surg 1986;77:427 436. 15. Mackinnon SE, Dellon AL. Results of treatment of recurrent dorsoradial wrist neuromas. Ann Plast Surg 1987;19:54 61. 16. Dellon AL, Aszmann OC. Treatment of supercial and deep peroneal neuromas by resection and translocation of the nerves into the anterolateral compartment. Foot Ankle 1998; 19:300 303. 17. Dellon AL. Treatment of recurrent metatarsalgia by neuroma resection and muscle implantation: case report and proposed algorithm for management of Mortons neuroma. Microsurgery 1989;10:256 259. 18. Wolfort SF, Dellon AL. Treatment of recurrent neuroma of the interdigital nerve by neuroma resection and implantation of the proximal nerve into muscle in the arch of the foot. J Foot Ankle Surg 2001;40:404 410. 19. Kim J, Dellon AL. Reconstruction of a painful posttraumatic medial plantar neuroma with a bioabsorbable nerve conduit: a case report. J Foot Ankle Surg 2001;40: 318 323. 20. Evans GRD, Dellon AL. Implantation of the palmar cutaneous branch of the median nerve into the pronator quadratus for treatment of painful neuroma. J Hand Surg 1994;19A: 203206. 21. Kim J, Dellon AL. Neuromas of the calcaneal nerves. Foot Ankle Int 2001;22:890 894. 22. Kim J, Dellon AL. Pain at the site of tarsal tunnel incision due to neuroma of the posterior branch of the saphenous nerve. J Am Podiatr Med Assoc, 2001;91:109 113.

4. Adani R, Cardon LJ, Castagnetti C, Pinelli M. Distal thumb reconstruction using a mini wrap-around ap from the great toe. J Hand Surg 1999;24B:437 442. 5. Foucher G, Medina J, Navarro R, Nagel D. Toe transfer in congenital hand malformations. J Reconstr Microsurg 2001; 17:17. 6. Beyaert C, Henry S, Dautel G, Martinet N, Betramo F, Lascombrs P, Andre, JM. Effect on balance and gait secondary to removal of the second toe for digital reconstruction: 5 year follow-up. J Pediatr Orthop 2003;23: 60 64. 7. Chu NS. Phantom nger phenomena and the effects of toe-to-nger transplantation. Neurorehabilitation and neural repair. 2000;14:277285. 8. Yang XB, Gu YD. The donor foot in free toe or joint transfers. J Hand Surg 2000;25B:382384. 9. Mackinnon SE, Dellon AL. Surgery of the peripheral nerve. Thieme Pub, 1988. 10. Meyer RA, Raja SN, Campbell JN, Mackinnon SE, Dellon AL. Neural activity originating from a neuroma in the baboon. Brain Res 1985;325:255260. 11. Dellon AL, Mackinnon SE, Pestronk A. Implantation of sensory nerve into muscle: preliminary clinical and experimental observations on neuroma formation. Ann Plast Surg 1984;12:30 40. 12. Mackinnon SE, Dellon AL, Hudson AR, Hunter DA. Alteration of neuroma formation by manipulation of its microenvironment. Plast Reconstr Surg 1985;76:345352. 13. Mackinnon SE, Dellon AL. The overlap pattern of the lateral antebrachial cutaneous nerve and supercial sensory branch of the radial nerve. J Hand Surg 1985;10A:522526.