Review Article
Primary Reconstruction for Thumb Amputation
Tsan-Shiun Lin*
Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital, Taiwan
*Corresponding author: Tsan-Shiun Lin, Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital, 123 Ta-Pei Road, Niao-Sung, Kaohsiung, 83305, Taiwan
Published: 20 Jun, 2018
Cite this article as: Tsan-Shiun Lin. Primary Reconstruction
for Thumb Amputation. Clin Surg. 2018;
3: 1991.
Abstract
Purpose: The goals of thumb reconstruction include restoration of its length, strength, position,
stability, mobility, sensibility and aesthetics. Compared to other techniques of secondary
reconstruction, it emphasizes the choice of primary reconstruction of the injured thumb for the
functional and aesthetic benefits.
Materials and Methods: When replantation is not possible, thumb reconstruction is necessary.
The technique of sub-dermal pocket is to afford a plenty venous drainage of microsurgical thumb
replantation in those cases that do not have a suitable venous plexus for reliable microanastomosis.
The composite graft technique associated with the sub-dermal pocket procedure is a feasible
resource when it is not possible to perform arterial revascularization of the amputated thumb tip.
The employment of the pedicled groin flap gives versatility and reproducibility to reconstruct
degloving thumb. One-stage debulking procedure is performed after division of flap. The full
thickness skin of the flap is first removed, fatty tissue is excised and the skin finally is regrafted.
Results: Based on the collected experience, the described procedures reach satisfactory results
concerning length, mobility, sensitivity and skin coverage for a correct work performance and
acceptable aesthetic outcomes.
Conclusion: The procedures for primary reconstruction of the thumb due to amputation or
degloving injury is a reasonable and feasible proposal to achieve satisfactory aesthetic and functional
results minimizing additional procedures or complications.
Introduction
The significant role of the thumb in hand function has been long understood: "on the length,
strength, free lateral motion and perfect mobility of the thumb depends the power of the human
hand" Sir Charles Bell [1]. It provides 40% of all hand function and as such traumatic amputation of
the thumb is associated with significant functional deficits [2].
By far, the most common cause necessitating thumb reconstruction is trauma. Within the larger
trauma classification, thumb injury can be the result of a variety of mechanisms, which include
sharp cut, avulsion and crush. There are some mechanisms that have characteristics of more than
one injury type. This phenomenon is best illustrated by saw and lawn mower injuries, which have
both cutting and crushing components, resulting in a larger zone of injury. Other insults that can
result in thumb loss requiring reconstruction include infections and neoplasms [3,4].
The advent of microsurgical techniques in the 1960s changed the way these injuries were
treated, progressing quickly from the laboratory to clinical practice, when on July 27, 1965, Tamai
and Komatsu performed the first successful thumb replantation [5-7]. When thumb loss occurs due
to trauma, replantation is the best method of reconstruction for most patients. When replantation
is not possible, thumb reconstruction is necessary [8-10].
The goals of thumb reconstruction include the restoration of thumb length, strength, position,
stability, mobility, sensibility, and aesthetics. It is a rare case when all of these objectives can be
achieved, and prioritization should be based on the goals and functional demands of the patient.
Reconstructive techniques vary widely, not only in their potential to achieve the above goals, but also
in their length of process, burden to the patient, and psychosocial implications. Patient education,
shared decision-making, and mutual commitment to a reconstructive plan are absolutely critical.
In addition to patient input regarding reconstructive methods, the patient must also commit to
the reconstructive process and must be a good candidate medically, socially, and psychologically. In
many patients, thumb injuries occur in the workplace, and these patients are affected by the injury
because their work requires significant hand use. In these patients,
it is essential to work toward a thumb that has adequate length for
both gripping and pinching, is stable during activities, has reasonable
motion, and is sensate to give tactile input during these actions and
to prevent recurrent ulceration or injury. However, adequate length,
stability, motion, and sensibility are the end goals for any patient
requiring thumb reconstruction, regardless of profession or vocation
[11-14].
Figure 1A
Figure 1B
Figure 1B
Sub-dermal pocket procedure for venous outflow after
revascularization with one digital artery.
Figure 1C
Figure 1D
Thumb Tip Injury
The distal phalanx is the back bone of the thumb tip. However,
the very distal tip includes only the soft tissues of the pulp and the nail
edge. The arterial supply of the thumb or fingertip consists of multiple
small branches of the digital arteries and the network of their terminal
branches. The terminal parts of the digital arteries are located around
the DIP joint level and the proximal half of the distal phalanges. The
digital arteries run along the sides of the digit, they have a diameter of
1 mm to 1.5 mm, which is sufficient for microsurgical anastomosis.
The arterial network beyond the middle of the distal phalanx is small
and difficult to suture. The main draining veins of the tip run as a
network on the dorsum of the digit. The digital arteries do not have
venae comitantes but there is a venous plexus in the subcutaneous
tissue surrounding each artery. Therefore, any flap based on a digital
artery must include 2 mm to 4 mm of subcutaneous tissues around
the artery and venous return is through the venous plexus around the
artery. The flexor tendons terminate on the palmar aspect of the distal
phalanx, and the digital nerves sent off terminal branches to form the
transverse arch in the palmar subcutaneous tissue of the pulp. The
branches of the digital nerves distal to the DIP joint are multiple and
are difficult, or impossible, to repair surgically.
Two of the more commonly referenced are by Allen and Hirase
[15,16]. Allen’s classification can be utilized preoperatively as it
employs gross landmarks to describe the level of amputation [15].
The Hirase classification system proposed that the level of injury in
relation to the level of anastomosis of the digital artery determined
the surgical method of reattachment [16]. An important distinction
of Hirase’s classification system is that the level of injury usually
cannot be determined preoperatively.
Composite Graft
The composite grafting technique has need of set up either the
distal edge of hurt thumb or detached tip for purposes of suturing
immediately. Debridement and cleanliness of the ends is mandatory,
taking off the fat of the tip and deepithelializing the injury end of the
thumb to allow a better contact surface with the graft. The own pulp
of the patient and its natural place achieves a satisfying result, either
the efficacy of surgical time (because only local anesthesia is need),
or the elevated rates of successes achieved in aesthetic outcomes
and functional recovery. Furthermore the defeat of finger length is
minimal comparing other methods [16-22]. For obtain better results
it should improve contact surfaces between the ends so that the
composite graft is adapted to skeletonized end of the thumb phalanx
as a cap.
The cooling of the composite graft confers a helpful effect on
its survival because it decreases tissue metabolism and avoids the
bacterial development [23,24]. The supply of prostaglandin E1,
which is a studied antiplatelet and peripheral vasodilator, has proved
satisfactory benefits as an additional pharmacological assistance
[24,25]. While it has not released detailed clinical information yet, the
enforcement of hyperbaric oxygen therapy in experimental animal
studies has revealed improvements during survival of grafts [26].
Tobacco smoking habit has been exposed as a statistically
significant risk factor for failure of vitality of composite graft,
according study by Heistein and Cook. Nevertheless, elderly patients,
who have diabetes or those have suffered a high energy injury can
achieve suboptimal results.
Figure 2A
Figure 2B
Sub-Dermal Pocket Procedure
The technique of sub-dermal pocketing derivates from
subcutaneous pocketing method and its premise is to afford a
plenty venous drainage of microsurgical thumb replantation in
those cases that do not have a suitable venous plexus for reliable
microanastomosis. Thus, it is feasible to provide the generation of an
early and plentiful angiogenesis [24,28-30]. It is well known that the
precise connection between both sub-dermal pocket and thumb tip
will allow generate a profuse network of vessels much more abundant
of vascular interconnections than will fascia layer [31].
The physiological progression is the equivalent to the graft
integration being the nourishment of the composite graft by serum
imbibition at the beginning, followed by inosculation and then a
concrete angiogenesis 48 hrs to 72 hrs later. Initially it is noted an
early congestion in the digital end that gradually becomes pink
appearance while one week has elapse [32].
It has been shown that neovascularization timing for separating
finger tips from its abdominal pocket was at least 1 week when
was made only arterial revascularization and no less than 2 weeks
when it was required composite grafting for replantation, from
studies published by Tsur et al. [32]. In the same way, report by
Han et al. [33] has showed that the new venous network, created
by neovascularization, was clarified at a mean of 7.6 days after the
abdominal pocket was made for fingertip replantation.
The sub-dermal pocketing procedure might be employed when
there is a complicated thumb tip injury due to possess various
advantages. This approach may be chosen for thumb tip injury which
has been revascularized with arterial anastomosis but does not have
available veins to make available venous drainage. It is preferred the
contralateral abdominal location as pocket place because this posture
is more pleasant for comfort of the patient.
An accurate contact of dermal tissue between pocket and thumb
tip allows a quick angiogenesis doing a period of time for their
division briefer than traditional subcutaneous pocket. Indeed, it is
much more profuse the vascular network that exists in dermis than
that is in their underlying layers. It can be kept an eye on the thumb
tip as a monitor and to observer the evolution of its integration or
revascularization so that if the process tends to fail noticing necrosis,
the approach could be interrupted in that moment [34].
The pocketing period of 2 weeks for thumb tips reconstructed
with composite graft procedure and 1 week before partition for
thumb tips revascularized with one digital arterial anastomosis
(Figure 1A-1D). Partial thickness of the dermal tissue is conserved
on the thumb tip for deepithelized thumb tip heals secondarily. The
nail bed must be restored scrupulously with 6-0 Dexon stitches if that
would be required [35].
Patients who have suffered cutting of thumb tip by guillotine
mechanism reveal better outcomes than those patients with crush
injury which has an unpredictable course when there is exposure of
the phalanx bone or tearing of the thumb pad. Similar, it is statistically
significant as success rates when it is achievable performing an arterial
anastomosis.
It has already been commented harmful and pernicious role of
smoking as a risk factor of importance for proper restoration of the
tip of the thumb due to its actions over microcirculation [36-38].
Figure 2C
Figure 2D
Groin Flap Pocketing and One-Stage Secondary Debulking Procedure
It is considered that the best solution as a treatment of thumb with
degloving injury is the immediate microsurgical revascularization. In
this sense, is required that the neurovascular elements are suitable
for this purpose. However, in many cases, this mechanism of trauma
makes both the neurovascular bundles as also its surrounding soft
tissue have suffered a significant injury by crushing, shearing and
torsion leading to the infeasibility of these tissues [39-47].
The collective proposal for immediate coverage of a thumb
due to degloving injury is the employment of the pedicled groin
flap described by McGregor and Jackson, given the versatility
and reproducibility of this technique [48,49]. It is noted that this
procedure involves separation of the pedicled flap at least two weeks
after the initial intervention, and it is in this circumstance when we
consider the opportunity to perform the debulking of the soft tissues
to optimize the aesthetic outcomes. The pedicled groin flap keeps on
one of the workhorses to cover many large defects in the hand and
forearm. This flap was published by Mc Gregor and Jackson in 1972
and was the first axial pattern flap described, and then the first flap
transferred microsurgically [50].
The one-stage secondary debulking procedure has revealed
excellent outcomes when the defatting of the flap is required,
according our experience in limb reconstruction. The overlying
skin was shown analogous and resilient of a normal thumb after the
subcutaneous defatting was performed because its full thickness skin
could not have trouble to stick to the subjacent tissue, under proper
contact between both surfaces. Without the interference of another
procedure, it follows that nerve regeneration is developed properly in
the dermis and thus a sensory improvement will be acceptable [51].
In summary, the approach with groin flap pocketing and onestage
secondary debulking procedure offers an undemanding
technique for non-replantable amputation or degloving injury of
thumb. The thin and strong skin coverage, that this technique can
offer, leads to perform pleasing cosmetic and functional necessities
(Figure 2A-2D).
Conclusion
We describe another proposal of primary thumb reconstruction with the use of sub-dermal pocket procedure when there is no available vein for venous drainage after rearterialization of the amputated thumb or using groin flap reconstruction and subsequent one-stage secondary debulking procedure when it is not possible to appeal thumb reimplantation. These methods can preserve the amputated thumb and prevent subsequent toe-to-thumb procedure.
References
- Thurston A. Vital endowments: Sir Charles Bell and the history of some congenital abnormalities of the upper limb. ANZ J Surg. 2011;81(12):900-4.
- Slocum DB, Pratt DR. Disability evaluation for the hand. J Bone Joint Surg Am. 1946;28:491-5.
- Littler JW. Principles of reconstructive surgery of the hand. In: Converse JM, editor. Reconstructive plastic surgery. 2nd ed. Philadelphia: WB Saunders; 1977;6:3137-42.
- Peter C Neligan. Plastic Surgery: Set: Expert Consult Premium Edition. 3rd ed. Elsiever Saunders; 2013;6.
- Amillo S, Leyes M, Fernández J, Torres R. Current indications for reimplantation of the upper extremity. Rev Med Univ Navarra. 1996;40(4):34-9.
- Kleinert HE, Kasdan ML. Restoration of blood flow in upper extremity injuries. J Trauma. 1963;3:461-76.
- Tamai S, Sasauchi N, Hori Y, Tatsumi Y, Okuda H. Microvascular surgery in orthopaedics and traumatology. J Bone Joint Surg Br. 1972;54(4):637-47.
- Allen DM, Levin LS. Digital replantation including postoperative care. Tech Hand Up Extrem Surg. 2002;6(4):171-7.
- Morrison WA, McCombe D. Digital replantation. Hand Clin. 2007;23(1):1-12.
- Li J, Guo Z, Zhu Q, Lei W, Han Y, Li M, et al. Fingertip replantation: determinants of survival. Plast Reconstr Surg. 2008;122(3):833-9.
- Ciclamini D, Tos P, Magistroni E, Panero B, Titolo P, Da Rold I, et al. Functional and subjective results of 20 thumb replantations. Injury. 2013;44(4):504-7.
- Haas F, Hubmer M, Rappl T, Koch H, Parvizi I, Parvizi D. Long-term subjective and functional evaluation after thumb replantation with special attention to the Quick DASH questionnaire and a specially designed trauma score called modified Mayo score. J Trauma. 2011;71(2):460-6.
- Unglaub F, Demir E, Von Reim R, Van Schoonhoven J, Hahn P. Long-term functional and subjective results of thumb replantation. Microsurgery. 2006;26(8):552-6.
- Lister G. The choice of procedure following thumb amputation. Clin Orthop Relat Res. 1985;(195):45-51.
- Allen MJ. Conservative management of finger tip injuries in adults. Hand. 1980;12(3):257-65.
- Hirase Y. Salvage of fingertip amputated at nail level: New surgical principles and treatments. Ann Plast Surg. 1997;38(2):151-7.
- Elsahy NI. When to replant a fingertip after its complete amputation. Plast Reconstr Surg. 1977;60(1):14-21.
- Venkatramani H, Sabapathy SR. Fingertip replantation: technical considerations and outcome analysis of 24 consecutive fingertip replantations. Indian J Plast Surg. 2011;44(2):237-45.
- Uysal A, Kankaya Y, Ulusoy MG, Sungur N, Karalezli N, Kayran O, et al. An alternative technique for microsurgically unreplantable fingertip amputations. Ann Plast Surg. 2006;57(5):545-51.
- Heistein JB, Cook PA. Factors affecting composite graft survival in digital tip amputations. Ann Plast Surg. 2003;50(3):299-303.
- Rose EH, Norris MS, Kowalski TA, Lucas A, Fleegler EJ. The “cap” technique: nonmicrosurgical reattachment of fingertip amputations. J Hand Surg. 1989;14(3):513-8.
- Gillies H, Reid DA. Autograft of the amputated digit. Br J Plast Surg. 1955;7(4):338-42.
- Hirase Y. Postoperative cooling enhances composite graft survival in nasal-alar and fingertip reconstruction. Br J Plast Surg. 1993;46(8):707-11.
- Eo S, Hur G, Cho S, Azari KK. Successful composite graft for fingertip amputations using ice-cooling and lipo-prostaglandin E1. J Plast Reconstr Aesthet Surg. 2009;62(6):764-70.
- Fann PC, Hartman DF, Goode RL. Pharmacologic and surgical enhancement of composite graft survival. Arch Otolaryngol Head Neck Surg. 1993;119(3):313-9.
- Friedman HI, Fitzmaurice M, Lefaivre JF, Vecchiolla T, Clarke D. An evidence-based appraisal of the use of hyperbaric oxygen on flaps and grafts. Plast Reconstr Surg. 2006;117(7 Suppl):175S-90.
- Li EN, Menon NG, Rodriguez ED, Norkunas M, Rosenthal RE, Goldberg NH, et al. The effect of hyperbaric oxygen therapy on composite graft survival. Ann Plast Surg. 2004;53(2):141-5.
- Brent B. Replantation of amputated distal phalangeal parts of fingers without vascular anastomosis, using subcutaneous pockets. Plast Reconstr Surg. 1979;63(1):1-8.
- Lee PK, Ahn ST, Lim P. Replantation of fingertip amputation by using the pocket principle in adults. Plast Reconstr Surg. 1999;103(5):1428-35.
- Kim KS, Eo SR, Kim DY, Lee SY, Cho BH. A new strategy of fingertip reattachment: Sequential use of microsurgical technique and pocketing of composite graft. Plast Reconstr Surg. 2001;107(1):73-9.
- McCraw JB, Dibbell DG. Experimental definition of independent myocutaneous vascular territories. Plast Reconstr Surg. 1977;60(2):212-20.
- Tsur H, Daniller A, Strauch B. Neovascularization of skin flaps: route and timing. Plast Reconstr Surg. 1980;66(1):85-90.
- Han SK, Chung HS, Kim WK. The timing of neovascularization in fingertip replantation by external bleeding. Plast Reconstr Surg. 2002;110(4):1042-6.
- Lin TS, Jeng SF, Chiang YC. Fingertip replantation using the subdermal pocket procedure. Plast Reconstr Surg. 2004;113(1):247-53.
- Lin TS, Yang JC. Secondary subdermal pocket procedure for venous insufficiency after digital replantation/revascularization. Ann Plast Surg. 2014;73(6):662-7.
- Goodwin SJ, McCarthy CM, Pusic AL, Bui D, Howard M, Disa JJ, et al. Complications in smokers after postmastectomy tissue expander/implant breast reconstruction. Ann Plast Surg. 2005;55(1):16-9.
- Al-Sarraf N, Thalib L, Hughes A, Tolan M, Young V, McGovern E. Effect of smoking on short-term outcome of patients undergoing coronary artery bypass surgery. Ann Thorac Surg. 2008;86(2):517-23.
- Aköz T, Akan M, Yildirim S. If you continue to smoke, we may have a problem: smoking's effects on plastic surgery. Aesthetic Plast Surg. 2002;26(6):477-82.
- Steichen JB, Russell RC, Strickland JW. Revascularization of ring avulsion injuries by microvascular technique. J Hand Surg. 1978;3:289.
- Urbaniak JR, Evans JP, Bright DS. Microvascular management of ring avulsion injuries. J Hand Surg Am. 1981;6(1):25-30.
- Weeks PM, Young VL. Revascularization of the skin envelope of a denuded finger. Plast Reconstr Surg. 1982;69(3):527-31.
- Tsai TM, Manstein C, Dubou R, Wolff TW, Kate JE, Kleinert HE. Primary microsurgical repair of ring avulsion amputation injuries. J Hand Surg Am. 1984;9A:68-72.
- Foucher G. Technique of ring injuries replantation. Plast Reconstr Surg. 1988;81(6):996-7.
- Tseng OF, Tsai YC, Wei FC, Staffenberg DA. Replantation of ring avulsion of index, long, and ring fingers. Ann Plast Surg. 1996;36(6):625-8.
- Adani R, Busa R, Castagnetti C, Castagnini L, Caroli A. Replantation of degloved skin of the hand. Plast Reconstr Surg. 1998;101(6):1544-51.
- Cheng SL, Chuang DC, Tung TC, Wei FC. Successful replantation of an avulsed middle finger. Ann Plast Surg. 1998;41(6):662-6.
- Akyürek M, Safak T, Keçik A. Ring avulsion replantation by extended debridement of the avulsed digital artery and interposition with long venous grafts. Ann Plast Surg. 2002;48(6):574-81.
- Kleinman WB, Dustman JA. Preservation of function following complete degloving injuries to the hand: use of simultaneous groin flap, random abdominal flap, and partial thickness skin graft. J Hand Surg. 1981;6(1):82-9.
- Senda H, Muro H, Terada S, Okamoto H. A case of degloving injury of the whole hand reconstructed by a combination of distant flaps comprising an anterolateral thigh flap and a groin flap. J Reconstr Microsurg. 2011;27(5):299-302.
- Lister GD, McGregor IA, Jackson IT. The groin flap in hand injuries. Injury. 1973;4(3):229-39.
- Lin TS. One-stage debulking procedure after flap reconstruction for degloving injury of the hand. J Plast Reconstr Aesthet Surg. 2016;69(5):646-51.