Complications and salvage of an ectopically replanted thumb

Complex Hand Reconstruction using a Novel Two-stage Temporary Ectopic Implantation of the Contralateral Upper Limb

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.

Usefulness of ectopic implantation in multiple finger amputation injury

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.

A series of rat segmental forelimb ectopic implantation models

Temporary ectopic implantation has been performed in clinical practice to salvage devascularized amputated tissues for delayed replantation purpose. In this study, we established a series of segmental forelimb ectopic implantation models in rats, including forelimb, forearm, forepaw, digit, and double forelimbs, to mimic the clinical context. Time of amputated limbs harvesting in donors and ectopic implantation process in recipients were recorded. Survival time and mortalities of recipients were also recorded. Sixty days after ectopic implantation, a full-field laser perfusion imager (FLPI) was used to detect the blood flow of amputated limbs and micro-CT imaging was used to examine bone morphological changes. Histological sections of amputated limbs were stained with hematoxylin and eosin to evaluate pathological changes. Implanted amputated limbs in all models achieved long term survival and there were no obvious morphological and histological changes were found according to results of micro-CT and histology study. Thus, a series of rat segmental forelimb temporary ectopic implantation models have been well established. To our knowledge, this is the first rodent animal model related to forelimb temporary ectopic implantation. These models might facilitate further research related to salvage, reconstruction and better aesthetic and functional outcome of upper extremity/digit in temporary ectopic implantation scenario.

Ectopic banking of amputated great toe for delayed thumb reconstruction: case report

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.

Challenges in replantation of complex amputations

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.

Local ectopic implantation for salvaging an amputated thumb: an anatomical study and a case report

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.

Ectopic banking of amputated parts: a clinical review

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.

Secondary ectopic transfer for replantation salvage after severe wound infection

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.

Great toe transplant versus thumb replant for isolated thumb amputation: critical analysis of functional outcome

BACKGROUND

Thumb replantation following thumb amputation is the standard of care. When replantation is impossible, microneurovascular great toe transplantation is a well-established option.

METHODS

A retrospective review was conducted to evaluate functional outcome following isolated thumb replantation or great toe transplantation for thumb reconstruction. From 1974 to 1993, 384 thumb amputations were treated and 110 great toe-to-thumb transplantations were performed.

RESULTS

Ninety-one patients with isolated thumb amputation had an 85% survival rate. Failed replants usually resulted from crushing or avulsing injuries. Function of replanted thumbs was better in sharp compared with crush/avulsion injuries. Forty-three isolated thumb reconstructions had a 93% success rate. Function was comparable with thumb replants from sharp injuries. Interphalangeal motion was significantly better in great toe transplants than in replanted thumbs of the crush/avulsion type.

CONCLUSIONS

Amputated thumbs should be replanted. When replantation is not possible or unsuccessful, a transplanted great toe functions as well as, or better than, a replanted thumb.

Temporary ectopic digital implantation: a clinical series of eight digits

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.

Temporary ectopic implantation of digits prior to reconstruction of a hand without metacarpals

Temporary ectopic implantation has been described for a variety of injuries, with several different implantation sites used. Although varied results have been achieved, many feel this technique has a role to play under special circumstances. We describe the ectopic implantation of digits to the contralateral forearm, with subsequent reconstruction of the injured hand when combined with microvascular toe transfer. The outcome was a functionally useful hand which could be incorporated into daily life, and a cosmetic appearance preferable to that of amputation. We feel ectopic implantation still has a valuable role to play in carefully selected cases.

Salvage of impending replant failure by temporary ectopic replantation: a case report

Temporary ectopic replantation of amputated parts has been reported previously as an alternative to orthotopic replantation in difficult cases. We report a case in which the left arm initially was replanted orthotopically with subsequent development of extensive infection. The impending vascular failure of the replanted arm was salvaged by reamputation and temporary ectopic transfer of the arm to the groin region. Nine days later the arm was transferred back to the clean humeral stump. The functional result was similar to that of a standard transhumeral replantation, with 30 degrees to 120 degrees of active range of elbow motion, basic grip pattern, and S3 sensibility.

La revascularisation digitale ectopique temporaire

We present two clinical cases with complete amputation of multiple digits that were salvaged after having been successfully implanted on ectopic sites. The first case concerns a 73-year-old patient, who suffered a severe crush injury of his right hand that resulted in amputation of all four long fingers and an extensive tissue loss of the palm and the dorsum of the hand. Two of the amputated digits, that were considered to be replantable, were implanted on the dorsum of the left foot. The hand defect was covered with a pedicle groin flap. After six weeks, the two ectopically implanted fingers were transferred to their proper anatomical site. Several reconstructive procedures were performed later, in order to lengthen the first ray of the injured hand, and to deepen the first web space. Satisfactory functional results were recorded after eighteen months of follow-up. The second patient concerns a 45-year-old male patient, who had a gun shot accident of his right hand. The injury resulted in a composite tissue loss of the hand with complete amputation of his four long fingers. All fingers were implanted on the left forearm, while the hand defect was reconstructed using an osteocutaneous free flap of the iliac crest. Six weeks after the initial procedure, the ectopically implanted digits were transferred - as a single free flap - to the hand. We described with details the local conditions of the injured hands in both cases, and discuss the reasons we decided to perform this sophisticated method in order to preserve the viability and function of those totally amputated fingers. The recipient sites were selected in a distance from the injured area, always considering the availability and size of appropriate recipient vessels, and the safety of the surgical procedure. We agree that the whole concept of this procedure is very demanding, and requires several microsurgical operations with high risk of complications. However, it does deserve special consideration in reconstructive microsurgery, since it offers the possibility to salvage multiple amputated digits, by preserving the anatomy and restoring the function of severely injured hands.

Temporary ectopic implantation for salvage of amputated lower extremities: Case reports

Two cases of temporary ectopic implantation of a complex amputated foot, followed by replantation to its anatomic position, are reported. Both cases of amputated foot were complicated by devastating soft-tissue injuries in the proximal stump of the amputation, fracture of the femur, and hemorrhagic shock, which ruled out the possibility of primary foot replantation. Both feet were temporarily ectopically implanted onto the contralateral legs, with microvascular anastomoses of the vessels to the recipient posterior tibial artery and saphenous vein. When the patient's general condition allowed, and the soft-tissue defects were repaired, the ectopic implanted feet were replanted to their anatomic positions. Both feet survived the temporary ectopic implantation and second-stage replantation. The length of the injured legs was maintained, and the feet regained their function in 4- and 6-month follow-ups. We conclude that temporary ectopic implantation of amputated parts provides an innovative procedure for the salvage of amputated extremities under special circumstances. A contralateral healthy extremity is an ideal recipient site for temporary ectopic implantation. The temporary ectopic implantation and second-stage replantation of an amputated foot and distal leg with indications can obtain satisfactory results.