61 Failed Replant: Failed Degloving Revascularization
61.1 Patient History Leading to the Specific Problem
A 27-year-old male patient sustained a degloving amputation of the right hand by a roller machine. All soft tissues of the index, long, ring, and small fingers were completely detached from the phalangeal bones and tendons distal to the digitopalmar crease. Even though there was vessel anastomosis between artery and vein, all replanted soft tissues were necrosed (▶Fig. 61.1).
The distal phalanx was disarticulated at the distal interphalangeal joint of all fingers (▶Fig. 61.2).
61.2 Recommended Solution to the Problem
The degloved digits require coverage with a flap. Free tissue coverage is an option, but that would require vein grafts into the forearm. A staged reconstruction can be achieved while keeping the hand elevated using the thoracoepigastric flaps and the medial arm flaps. These are random flaps that will be used to create a surgical syndactyly with subsequent separation of the digits after neovascularization of the flaps from surrounding tissue. This often takes 2 to 3 weeks. The syndactylized digits will remain in that disposition for 2 to 3 months and then debulked and separated. Skin grafts may be needed to obtain full closure.
The soft-tissue defect of the palmar area was covered with anterior chest flap and the dorsal area covered with medial upper inner arm flap (▶Fig. 61.3).
Before resurfacing the degloved fingers, two steps are mandatory to achieve successful postoperative results. Revision amputation of the distal phalangeal bone should be carried out. If not, the distal phalangeal bone inside the flap becomes necrosed due to insufficient perfusion through the flap. Transverse fixation on the adjacent proximal phalangeal bones is also necessary to avoid narrowing of the interdigital spaces as the flap shrinks. Temporary longitudinal Kirschner’s wire fixation prevents flexion contracture of the finger inside the flap. In some cases, disarticulation at the proximal interphalangeal joint is also required. The importance of preservation of the first web space and interdigital web space cannot be overemphasized.