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Long H, Wu D, Yan Z, Jia S, Chen JR, Lim RQR. Complex Hand Reconstruction using a Novel Two-stage Temporary Ectopic Implantation of the Contralateral Upper Limb. Orthop Surg 2024; 16:2093-2099. [PMID: 38961655 PMCID: PMC11293938 DOI: 10.1111/os.14147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 06/08/2024] [Accepted: 06/09/2024] [Indexed: 07/05/2024] Open
Abstract
Ectopic transplantation of the hand remains a rare, innovative yet valuable operation in select cases of trauma and amputation. We aim to describe a novel technique of complex hand reconstruction using a two-stage ectopic implantation of the contralateral upper limb. A male patient with a near complete avulsion amputation of the right upper limb at the level of the mid-forearm and a crushing injury to his left hand was admitted after a farming accident. The right palm was ectopically transplanted to the left lower limb and both upper limbs underwent debridement with vacuum assisted dressings (VACs). There was eventual dieback of the left thumb, ring and little finger with a large palmar soft tissue defect that was eventually reconstructed using segments of the ectopically transplanted limb in two separate operations. The patient made an uneventful postoperative recovery and managed to regain protective sensation and gross motor function of his reconstructed hand.
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Affiliation(s)
- Haiquan Long
- Department of Upper Limb MicrosurgeryShenzhen Baoan District People's HospitalShenzhenChina
| | - Di Wu
- Department of Upper Limb MicrosurgeryShenzhen Baoan District People's HospitalShenzhenChina
| | - Zuojie Yan
- Department of Upper Limb MicrosurgeryShenzhen Baoan District People's HospitalShenzhenChina
| | - Sailing Jia
- Department of Upper Limb MicrosurgeryShenzhen Baoan District People's HospitalShenzhenChina
| | - Jin Ren Chen
- Department of Upper Limb MicrosurgeryShenzhen Baoan District People's HospitalShenzhenChina
| | - Rebecca Qian Ru Lim
- Department of Hand & Reconstructive MicrosurgerySingapore General HospitalSingaporeSingapore
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Yu L, Shah K, Meng F, Wan S, Xiao Y, Yu F, Zhou Z. Ectopic multiple digit replantation salvage of hand torsion injury following anterolateral thigh perforator flap coverage. JPRAS Open 2023; 38:201-205. [PMID: 37929061 PMCID: PMC10624565 DOI: 10.1016/j.jpra.2023.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 10/10/2023] [Indexed: 11/07/2023] Open
Abstract
Retrieval of four finger injury at proximal stump amputation with segmental injury along with soft tissue defect and impending compartment syndrome continues to be challenge for the surgeon. Immediate transplant considering temporary ectopic foster as a practical option in special case. We describe temporary ectopic finger implant for crush injury at Metacarpophalangeal (MCP level) with hand torsion along with forearm compartment was fostered to Dorsum of the foot. The torsion fingers was temporary fixed with mini external fixator for stabilization as salvage, ALT free flap was used to cover soft tissue defect of the hand. Replantation of survived figure was performed using the long pedicle to anatomical site without crushing the MCP joint to allow for later tendon transfer for finger. Satisfactory function regained with no foster site (foot) complication like pain or disability. The author validated ectopic foster for amputee as and procedure of choice for salvage of extremity under special circumstances.
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Affiliation(s)
- Longbiao Yu
- Hand and Microsurgery department, Peking University Shenzhen Hospital, Shenzhen, China
| | - Kushal Shah
- Deptartment of Plastic Surgery, Bai Jerbai Wadia Hospital for Children Mumbai, India
| | - Fanbin Meng
- Hand and Microsurgery department, Peking University Shenzhen Hospital, Shenzhen, China
| | - Shengxiang Wan
- Hand and Microsurgery department, Peking University Shenzhen Hospital, Shenzhen, China
| | - Yingfeng Xiao
- Hand and Microsurgery department, Peking University Shenzhen Hospital, Shenzhen, China
| | - Fei Yu
- Department of Bone & Joint Surgery, Peking University Shenzhen Hospital, Shenzhen, China
- National & Local Joint Engineering Research Center of Orthopaedic Biomaterials, Shenzhen, China
- Shenzhen Key Laboratory of Orthopaedic Diseases and Biomaterials Research, Shenzhen, China
| | - Zhegang Zhou
- Hand and Microsurgery department, Peking University Shenzhen Hospital, Shenzhen, China
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3
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Yoshida S, Koshima I, Narushima M, Nagamatsu S, Yokota K, Yamashita S, Harima M. Usefulness of ectopic implantation in multiple finger amputation injury. Clin Case Rep 2019; 7:546-549. [PMID: 30899491 PMCID: PMC6406161 DOI: 10.1002/ccr3.2040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 01/11/2019] [Accepted: 01/14/2019] [Indexed: 11/22/2022] Open
Abstract
Replantation combined with simultaneous ectopic implantation can be considered in patients with multiple finger amputation injury. This technique has the advantages of reducing the operating time and optimizing hemodynamic stability. However, it is only possible when multiple hand and microsurgery team can be organized at short notice.
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Affiliation(s)
| | - Isao Koshima
- International Center for Lymphedema (ICL)HiroshimaJapan
| | | | - Shogo Nagamatsu
- Plastic and Reconstructive SurgeryHiroshima University HospitalHiroshimaJapan
| | - Kazunori Yokota
- Plastic and Reconstructive SurgeryHiroshima University HospitalHiroshimaJapan
| | - Shuji Yamashita
- Department of Plastic and Reconstructive SurgeryGraduate School of MedicineThe University of TokyoTokyoJapan
| | - Mitsunobu Harima
- Department of Plastic and Reconstructive SurgeryGraduate School of MedicineThe University of TokyoTokyoJapan
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Temporary ectopic implantation for salvaging amputated parts: A systematic review. J Trauma Acute Care Surg 2018; 84:985-993. [DOI: 10.1097/ta.0000000000001817] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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5
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Valerio IL, Hui-Chou HG, Zelken J, Basile PL, Ipsen D, Higgins JP. Ectopic banking of amputated great toe for delayed thumb reconstruction: case report. J Hand Surg Am 2014; 39:1323-6. [PMID: 24799146 DOI: 10.1016/j.jhsa.2014.03.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 03/17/2014] [Accepted: 03/18/2014] [Indexed: 02/02/2023]
Abstract
Ectopic banking of amputated parts is a recognized technique for delayed replantation of an amputated part when the amputation stump will not permit immediate replantation. This is conventionally performed with the intent of transferring the injured part back to its anatomic position when the amputation stump is more appropriate for replantation. Current warfare conditions have led to a commonly encountered military trauma injury pattern of multiple extremity amputations with protected trunk and core structures. This pattern poses many challenges, including the limit or absence of donor sites for immediate or delayed flap reconstructive procedures. We describe a case in which we ectopically banked the great toe of an amputated lower extremity for delayed thumb reconstruction.
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Affiliation(s)
- Ian L Valerio
- Plastic and Reconstructive Surgery Service, and the Hand Surgery Service, Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda; Johns Hopkins/University of Maryland Plastic and Reconstructive Surgery Program, Baltimore; Role 3 Multinational Medical Unit (MMU), Kandahar, Afghanistan; Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD.
| | - Helen G Hui-Chou
- Plastic and Reconstructive Surgery Service, and the Hand Surgery Service, Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda; Johns Hopkins/University of Maryland Plastic and Reconstructive Surgery Program, Baltimore; Role 3 Multinational Medical Unit (MMU), Kandahar, Afghanistan; Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD
| | - Jonathan Zelken
- Plastic and Reconstructive Surgery Service, and the Hand Surgery Service, Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda; Johns Hopkins/University of Maryland Plastic and Reconstructive Surgery Program, Baltimore; Role 3 Multinational Medical Unit (MMU), Kandahar, Afghanistan; Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD
| | - Patrick L Basile
- Plastic and Reconstructive Surgery Service, and the Hand Surgery Service, Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda; Johns Hopkins/University of Maryland Plastic and Reconstructive Surgery Program, Baltimore; Role 3 Multinational Medical Unit (MMU), Kandahar, Afghanistan; Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD
| | - Derek Ipsen
- Plastic and Reconstructive Surgery Service, and the Hand Surgery Service, Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda; Johns Hopkins/University of Maryland Plastic and Reconstructive Surgery Program, Baltimore; Role 3 Multinational Medical Unit (MMU), Kandahar, Afghanistan; Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD
| | - James P Higgins
- Plastic and Reconstructive Surgery Service, and the Hand Surgery Service, Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda; Johns Hopkins/University of Maryland Plastic and Reconstructive Surgery Program, Baltimore; Role 3 Multinational Medical Unit (MMU), Kandahar, Afghanistan; Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD
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Chim H, Maricevich MA, Carlsen BT, Moran SL, Salgado CJ, Wei FC, Mardini S. Challenges in replantation of complex amputations. Semin Plast Surg 2014; 27:182-9. [PMID: 24872767 DOI: 10.1055/s-0033-1360585] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Surgical ingenuity has resulted in continuing microsurgical innovation in replantation. In this article, the authors define complex amputations as those that stretch the boundaries or fall outside traditionally defined indications for replantation. They discuss management of difficult situations involving multiple digit amputations, multiple-level amputations, prolonged ischemia, and multiple trauma. The role of transpositional and ectopic replantation, as well as the requirement for secondary procedures in replantation is also discussed. Although technically challenging, microsurgical management of complex amputations ultimately results in far superior outcomes.
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Affiliation(s)
- Harvey Chim
- Department of Plastic Surgery, Case Western Reserve University, Cleveland, Ohio
| | | | - Brian T Carlsen
- Division of Plastic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Steven L Moran
- Division of Plastic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Fu-Chan Wei
- Department of Plastic Surgery, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Samir Mardini
- Division of Plastic Surgery, Mayo Clinic, Rochester, Minnesota
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Local ectopic implantation for salvaging an amputated thumb: an anatomical study and a case report. Ann Plast Surg 2013; 70:187-91. [PMID: 23328124 DOI: 10.1097/spa.0b013e31823b67ca] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Relatively few cases of the ectopic implantation of an amputated thumb have been reported. The majority of ectopic sites are far from the original anatomic site, and anastomosis of the artery cannot be avoided in the secondary replantation surgery, which increases the failure rate. We conducted an anatomic study to investigate the possibility of performing local ectopic implantation of an amputated thumb at the wrist level such that an arterial pedicled thumb could be harvested in the secondary surgery. Thirty radial arteries were dissected from the point 3 cm proximal to the radial styloid to the point at which they passed over the radial styloid. Each branch with a diameter >0.8mm was selected. The mean number of branches was 3.2 > ± 1.37, and the mean diameter was 1.09 ± 0.83 mm. The mean diameter of the ulnar digital artery in the thumb was 1.08 ± 0.15 mm at the metacarpophalangeal joint level. Following anatomic research, an amputated thumb was ectopically implanted locally and replanted during a secondary operation without anastomosis of the artery. The amputated thumb survived, and its function was partially restored. In conclusion, the branches of the radial artery that have a similar diameter to the ulnar digital artery of the thumb can always be located at the wrist level. Local ectopic implantation is feasible and can help prevent the need for anastomosis of the artery during the secondary replantation surgery.
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Higgins JP. Ectopic banking of amputated parts: a clinical review. J Hand Surg Am 2011; 36:1868-76. [PMID: 22036286 DOI: 10.1016/j.jhsa.2011.09.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2010] [Accepted: 09/01/2011] [Indexed: 02/02/2023]
Abstract
Since its first clinical description by Marco Godina in 1986, the technique of temporary ectopic banking of amputated parts has been employed in a growing body of reported cases. This installment provides a review of the reported cases in the international literature to date, focusing on our evolving understanding of clinical indications, operative timing, and surgical technical consideration. Two illustrative cases are provided to highlight these concepts.
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Affiliation(s)
- James P Higgins
- Curtis National Hand Center, Union Memorial Hospital, Baltimore, MD 21218, USA.
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Sabapathy SR, Venkatramani H, Bharathi RR, Bhardwaj P. Replantation surgery. J Hand Surg Am 2011; 36:1104-10. [PMID: 21636026 DOI: 10.1016/j.jhsa.2011.03.039] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2011] [Accepted: 03/31/2011] [Indexed: 02/02/2023]
Abstract
The current concepts of replantation surgery, a procedure that has been practiced for half a century, can be discussed in terms of patients' demands and expectations, present indications for the procedure, available evidence that influences decision making, and technical refinements practiced to produce better outcomes.
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Affiliation(s)
- S Raja Sabapathy
- Department of Plastic, Hand, and Reconstructive Microsurgery, Ganga Hospital, Tamil Nadu, India.
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Cavadas PC, Landin L, Thione A. Secondary ectopic transfer for replantation salvage after severe wound infection. Microsurgery 2011; 31:288-92. [PMID: 21557306 DOI: 10.1002/micr.20851] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2010] [Revised: 10/03/2010] [Accepted: 10/05/2010] [Indexed: 11/11/2022]
Abstract
BACKGROUND Ectopic transfer has been described as a salvage procedure in failing replants. The experience in three cases of infected failing replantations treated with secondary temporary ectopic transfer of the replanted part is presented. METHODS Three patients with replanted traumatic amputations (one transhumeral, one transmetacarpal, and one transtibial) that developed severe wound infections and thrombosis of the anastomoses were treated with urgent ectopic transfer of the replanted part. The ectopic recipient vessels were the femoral, posterior tibial, and the descending branch of the lateral femoral circumflex arteries. The stumps were surgically cleansed and the ectopically replanted parts were retransferred some days later. RESULTS The infection reccurred in one case and the replant (transmetacarpal) was lost. The two other cases were successfully retransferred orthotopically, 9 and 20 days later, respectively. In one case (transtibial) multiple additional surgical procedures were necessary. Functional results in these two cases were acceptable. CONCLUSIONS Delayed ectopic transfer is a useful, yet demanding technique for the salvage of complicated replants in the context of severe wound infection and vascular thrombosis or impending failure. Given the complexity of the procedure it should only be considered in selected cases.
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Affiliation(s)
- Pedro C Cavadas
- Hand Surgery and Reconstructive Surgery Unit, Clínica Cavadas, Valencia, Spain.
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Cavadas PC, Landín L, Ibáñez J. Temporary catheter perfusion and artery-last sequence of repair in macroreplantations. J Plast Reconstr Aesthet Surg 2009; 62:1321-5. [DOI: 10.1016/j.bjps.2008.04.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2007] [Revised: 03/25/2008] [Accepted: 04/03/2008] [Indexed: 10/21/2022]
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Ectopic single-finger transplantation, a novel technique for nonreplantable digits: assessment of 24 cases--presenting the "piggyback" method. Tech Hand Up Extrem Surg 2009; 13:65-74. [PMID: 19516130 DOI: 10.1097/bth.0b013e31818d5444] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Twenty-four cases of ectopic single-finger transplantation are reported using our new "piggyback" technique for finger transfer that simplifies, with a high success rate, the hazardous second-stage transfer. Twenty-four patients (mean age, 20 years) were treated for severely crushed proximal stumps with a replantable distal part (zones 1 and 2a). In this method, after a successful ectopic transplantation, the transplanted part is transferred to the original site not as a free tissue transfer but as a pedicle flap in which the transplanted finger is piggybacked to the groin flap and then the composite tissue (groin and finger) is transferred to the stump. After a waiting period of 3 to 4 weeks, the flap is severed sequentially or in 1 setting. Graft take, complications, sensitivity, patient satisfaction, and demographic data of the patients were evaluated.Graft take was 75% in the first stage and 100% in the second stage. There were no cases of infection, and minor complications such as edema subsided with time. Distal finger amputations have the best indication for replantation. A Pearson Educational Measurement score was obtained from the patients who participated in 6-month and 1-year follow-ups, and at the end of 1 year, 85% of the patients scored above 45 points. Eighty-seven percent of the patients were satisfied with their results and stated they would choose this procedure again if indicated and also would recommend it to other patients.The piggyback method of transfer of the ectopic single-finger transplantation has simplified the arduous and risky second-stage transfer to a low-risk and highly successful operation. The advantages include a less bulky tissue transfer, no severed major artery, and 2 short surgical procedures replacing 1 lengthy, potentially risky free vascularized procedure. The only drawback of this technique is the 3-week waiting period for the pedicle flap, wherein the hand is attached to the groin. The reconstruction of the nerve, artery, and tendon and, sometimes, when it is not possible to accomplish proper bone fixation at the second stage, can be achieved with ease after severing the pedicle.
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Bakhach J, Katrana F, Panconi B, Baudet J, Guimberteau JC. Temporary ectopic digital implantation: a clinical series of eight digits. J Hand Surg Eur Vol 2008; 33:717-22. [PMID: 18694920 DOI: 10.1177/1753193408091429] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
This paper reports our experience with temporary ectopic digital implantation. Four patients suffered 12 digital amputations with large defect over the proximal stumps. Only 8 digits were suitable for microsurgical salvage but the local conditions made direct replantation impossible. In our first patient, the two digits were ectopically implanted onto the foot, while in the second patient the four amputated digits were implanted onto the opposite forearm. After stump reconstruction, the digits were microsurgically transferred to the hand, restoring a functional pinch. One digit suffered a venous congestion and necrosis in the ectopic site caused by a haematoma and another experienced a no-reflow phenomenon. In conclusion, temporary ectopic implantation remains a procedure that can be used to salvage amputated digits.
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Affiliation(s)
- J Bakhach
- Institut Aquitain de Chirurgie Plastique, Reconstructrice et Esthétique, Chirurgie de la Main et MicrochirurgiePessac, Bordeaux, France.
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Cavadas PC. Salvage of replanted upper extremities with major soft-tissue complications. J Plast Reconstr Aesthet Surg 2007; 60:769-75. [PMID: 17478136 DOI: 10.1016/j.bjps.2007.03.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2006] [Revised: 02/17/2007] [Accepted: 03/07/2007] [Indexed: 11/25/2022]
Abstract
Soft-tissue complications in the replantation wound, either septic or non-septic, are the main cause of failure in major extremity replantations. In the presence of necrosis or infection, vascular errosion or thrombosis readily develops and can lead to limb loss. Very aggressive surgical treatment has been recommended to salvage the replanted limb in these highly unstable clinical situations. Over a 10-year period, 423 amputated parts were replanted, 56 of which were replants proximal to the wrist. The experience of the author in treating 11 cases of critical soft-tissue necrosis (four septic and seven non-septic) after major replantation of the upper extremity with aggressive debridement and flap coverage, is reported. All flaps and limbs survived.
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