58 Failed Replant: Ray Amputation
58.1 Patient History Leading to the Specific Problem
A 36-year-old woman sustained a complete amputation of the left index finger through the proximal phalangeal bone. The patient was taken to the operating room emergently. An attempt at replantation failed (▶Fig. 58.1).
58.2 Anatomic Description of the Patient’s Current Status
The patient had an amputation of the index finger at the level of the mid-proximal phalanx. There was no movement of the phalanx, which was too short to be functional.
58.3 Recommended Solution to the Problem
• Revision amputation at the just proximal part of replantation is performed by denuding articular cartilage, shaping the condyles of the proximal phalanx, and employing tension-free skin closure.
• Primary ray amputation shortens lost work time, eliminates the cost of a second procedure, and improves cosmetic appearance.
• Second toe-to-hand transfer for the digits recovers a normal appearance and also maintains the original digit length, but consideration of donor site morbidity and risk of operation failure must be taken.
Through a Y-shaped incision on the dorsal surface of the metacarpophalangeal joint area, the extensor tendons and the first dorsal interossei muscle are divided at the level of the second metacarpal base. After striping of the dorsal periosteum, the second metacarpal is transected in a bevel design at the metacarpal base (▶Fig. 58.2).
At least 1 cm of the metacarpal bone should be left to preserve the insertion of the extensor carpi radialis longus tendon. On the palmar aspect, the digital artery to the radial side of the index finger is ligated and the digital nerves dissected distally into the proximal phalangeal segment and divided. When the ulnar digital nerve of the index finger is resected, the radial digital nerve and accompanying digital artery of the long finger should be protected. The digital nerves should be transected as far proximally as possible to prevent painful neuroma formation. The flexor tendons of the index fingers are pulled distally and transected. The first palmar interosseous tendon, volar plate, transverse intermetacarpal ligament, and proximal portion of the flexor tendon sheath are sharply resected. The rough edge of the distal end of the metacarpal bone should be smoothened by a rasp. The tendon of the first dorsal interosseous muscle is transferred to the radial lateral band of the long finger for good abduction of the long finger for pinching and for a smooth, contoured first web space between the thumb and long finger. The extensor indicis proprius tendon is transferred to the extensor hood of the long finger to make a new primary pincher and manipulator for more independent extension (▶Fig. 58.3).