I began by isolating a peripheral nerve that satisfied four conditions:

1) Can be accessed via simple blunt dissection

2) I can establish a reasonably comfortable surgical position

3) The nerve must not have any major blood vessels surrounding it to reduce the risk of iatrogenic injury (injury caused by surgery

4) Can be easily anesthetized via local anesthetic

I found the proper plantar digital nerve of the second toe to be the best option (this is the toe next to the big toe. there are two proper plantar digital nerves that span the length of the underside of the toe, flanked by the phalanges).

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To begin, I studied the anatomy of the toes and foot. I also searched for procedures involving dissection of the toes on Medtube and Youtube. However, there exists no procedures publicly available for isolation of the digital nerves in toes other than the hallux (big toe). I had to make due, by watching surgeries on the closest option: fingers. I learned about digital nerve surgery from Dr. Susan Mackinnon and Dr. Vaikunthan Rajaratnam and the common methods of dissection for digits.

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Anesthetic:

I cannot get my hands on traditional anesthetic for these procedures (typically 1-2% lidocaine), so I had to make due with what I could purchase, which are carpules of 3% Carbocaine. After reviewing anatomy of digits again and watching nerve block procedures for digits, I performed a nerve block on my second toe with success. Specifically, it was a ring block in which I blocked both dorsal digital nerves first, then both plantar nerves. The anesthetic I purchased worked and maintained its effect for approximately and hour.

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Bloodless Field:

It is best to have a completely bloodless field when doing surgery so that the surgeon has visibility of all structures during dissection. To do this, the surgical area should be exsanguinated (remove all blood). I found that using Esmark bandages and gradually wrapping the foot from toes to ankle is an excellent way of squeezing most of the blood out of my foot. To maintain the bloodless field during surgery, I created a simple tourniquet with the Esmark bandages around the ankle.

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Suturing:

I practiced suturing on a suture pad (which ironically feels nothing like human skin). I found that 3/8 circle 19mm 4 0 nylon sutures were the best option

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Electrodes:

I purchased cuff electrodes from CorTec.

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Antibiotics:

I had azithromycin (oral usage) and silver sulfadiazene (topical)

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Procedure:

1) Clean the surgical field. Boil all tools for 10 minutes and place in ethanol bath for 5 min. Remove all tools and dry the ethanol off.

2) Perform nerve ring block on all digital nerves in the second toe using 3% Carbocaine with a 27 gauge needle. Approximate volume usage is about 2 mL.

3) Raise the leg up while laying on back and exsanguinate the foot and toe using Esmark bandages and promptly tourniquet at the ankle. Note the time of tourniquet (maximum time 2 hours before arterial and tissue damage).

4) Begin Bruner incision with a #15 scalpel at the first phalanx. Use retraction as needed and perform blunt dissection (I used tenotomy scissors in a spreading motion). Extension of the Bruner incision proximally may be necessary. Note that it is best to stay proximal as the nerve will be larger.

5) Identify the nerve and begin isolation from connective tissue. Use wide retraction to open up the incision as implantation of the cuff electrode will need a large area to open the cuff. Using two blunt tweezers, open the cuff such that the inside is facing the nerve and place the electrode directly over the nerve. Release the cuff. It should close securely around the nerve.

6) Flush the incision site with saline and begin suturing. Ensure the wires are not pierced by the needle.

7) Remove tourniquet. Take avaible antibiotics for two days and apply a topical antibiotic (silver sulfadiazene). Full wound closure will occur in approximately 4 weeks.