A 22-year-old woman presented 4 hours after suffering a zone 3 amputation of all fingers at the distal metacarpal level of the right hand. The little finger was severely crushed (▶Fig. 62.1). The mechanism of injury was by crush and torsion. Although it was a relative indication for revision amputation, due to the age of the patient and her very good health status, replantation was attempted.
The patient presented a zone 3 metacarpal amputation with deglovement of the dorsal aspect of the hand. The little finger was completely mangled. The remaining metacarpals were comminuted fractures with a 2-cm defect.
After a careful irrigation and debridement and metacarpal shortening, it was decided to try the replantation. In the second postoperative day, signs of arterial sufferance appeared: pallor and loss of capillary refill. The patient was readmitted in the operating room and the arterial anastomoses were checked. All three sutured arteries were found with thrombosis. After resection of the thrombosed segments, the arteries were reconstructed with 3-cm-long venous grafts. A good revascularization was obtained. Unfortunately on the fourth postoperative day, the thrombosis reappeared, which determined the reamputation (▶Fig. 62.2). The stump remained opened and, after obtaining a good granular bed 7 days later, the reconstruction was planned (▶Fig. 62.3).
Taking into account the mechanism of injury and the aspect of the lesion, maybe it would have been better not to try the replantation. However, the indication was a little forced by the age of the patient and because she was right handed. Sometimes it would be better to start the reconstruction immediately.
Being the dominant hand, the functional reconstruction is mandatory in such a case. The reconstruction should be done as soon as possible to allow the rehabilitation program to start very early.
Multistage or single-stage reconstructions can be considered the possible solutions.
• Skin defect coverage by using split-thickness skin graft or a flap.
• Secondary reconstruction of the prehensile function by using toe(s) transfer.
• Using combined toe(s) transfer and dorsalis pedis flap.
• Using a free flap and toe(s) transfer separately vascularized.
• Using toe(s) transfer revascularized through a free flow-through flap.
• Regarding the toe transfer, it is possible to use a single toe, two toes (one from each foot), or a digital block of two toes from the same foot.
Considering the large dimensions of the skin defect and the amputation level proximal to the metacarpal head, our option was to use a free anterolateral thigh (ALT) flow-through perforator flap and a toe transfer of the second and third toes from the right foot.
The patient is placed in the supine position. The surgery is done under general anesthesia and a two-team approach.
2. Right thigh.
3. Right foot.
The hand is prepared with disinfecting solutions and an arm tourniquet is applied. The wound is debrided and the tendon and nerve stumps are identified and isolated. The dorsal branch of the radial artery (RA) in the anatomical snuffbox and the cephalic vein (CV) are identified and isolated.
The right lower limb is prepared with disinfecting solutions. Using a handheld Doppler, the perforators’ location on the anterolateral aspect of the thigh is determined. An ALT flap of 15 × 10 cm is designed, centered on the most powerful perforator, located at 15 cm below the anterior iliac crest. An incision following the anterior edge of the flap is performed, and the skin is undermined until the identification of the perforator, which is a septocutaneous one. The perforator is dissected until its origin from the descending branch of the lateral circumflex femoral (DBLCF) artery. Then, the DBLCF is dissected for a 15-cm length. The complete incision and dissection of the entire flap is performed and, after cutting the vascular pedicle proximally and distally, the flap is harvested (▶Fig. 62.4). The donor site of the flap is closed partially by direct suture and the remaining 6 × 4 cm defect is skin grafted.
A second surgical team starts the harvesting of the composite second and third toes. A tourniquet is placed on the thigh above the knee. A transversal incision is performed 1 cm proximal to the second and third metatarsophalangeal (MP) joints continued longitudinally over the first intermetatarsal space. The skin over the second and third metatarsals is carefully dissected with identification and isolation of three veins draining in a main branch of the dorsal arch (▶Fig. 62.5). The first intermetatarsal artery (IMA) is identified and dissected until the origin from the dorsalis pedis artery. The branch for the big toe and the deep plantar artery are ligated and cut. The transversal incision is prolonged transversally over the plantar aspect of the foot 1 cm proximally to the second and third MP joints. A careful dissection is performed, with the identification of the digital nerves and flexor and extensor tendons, which are cut. Then, the second and third metatarsals are prepared and cut 3 cm proximal to the MP joints. The tourniquet is released and the revascularization of the toes is checked. The first signs of revascularization appear after 20 minutes (▶Fig. 62.6a). The artery and vein are cut (▶Fig. 62.6b) and the donor site is directly closed.