Arch Hand Microsurg.  2022 Sep;27(3):265-269. 10.12790/ahm.22.0002.

Thumb reconstruction with a double flap after thumb replantation failure using a reverse homodigital dorsoulnar flap and a cross-finger flap: a case report

• Yong MJ
• Mo YW
• Shin HK

• KMID: 2532744
• DOI: http://doi.org/10.12790/ahm.22.0002

Abstract

After replantation and salvage procedures have failed in a heavy smoker, surgeons are hesitant to consider future strategies. We introduce a case in which the length and function of the right thumb were preserved as much as possible by double flap surgery after replantation failure. The thumb of a 55-year-old man without underlying disease was amputated by an electrical chainsaw at work. He presented at the emergency room of our hospital, and emergency surgery was performed for exploration and stump replantation. Unfortunately, the replantation surgery failed, and the distal stump was necrotized. Thus, double flap surgery was planned after replantation failure, and thumb reconstruction was performed using a reverse homodigital dorsoulnar flap and a cross-finger flap. A portion of the flap later had to be revised, but the functional and aesthetic results obtained were far better than expected for a simple stump revision procedure.

Keyword

Amputation; Replantation; Surgical flaps; Thumb

Figure

• 

  Fig. 1. (A, B) Postoperative photographs showing distal skin necrosis from stump distal pulp 2 days after surgery. Flap compromise at the stump was also detected.

• 

  Fig. 2. Stump revision surgery after replantation failure showing completed reverse homodigital dorsoulnar flap, cross-finger flap, and hatchet flap placement and thumb reconstruction. (A) Homodigital reverse island flap and cross-finger flap were designed for thumb coverage. (B) Necrotic soft tissue of the stump was removed, and arthrodesis of the distal interphalangeal joint was performed using Kirschner wires. (C) A reverse homodigital dorsounlar flap was elevated and transposed to the dorsal surface of distal phalanx. (D, E) Cross-finger flap for volar surface of distal phalanx. (F, G, H) The donor site of the reverse homodigital island flap was covered with hatchet flap. The donor defect of the index finger was covered with full-thickness skin graft and tie-over dressing was applied.

• 

  Fig. 3. (A, B) Three weeks after the flap surgery, flap division was performed, and at this time, additional debridement and ostectomy were performed. (C, D) The thumb length was nearly conserved as seen in the figures.

• 

  Fig. 4. (A, B, C) After flap division surgery, patient's thumb results in the formation with a finger-like skin texture and maintains a length. (D) Patient's thumb is performed such that flexion, opposition and adduction are made possible by maintaining interphalangeal joint function. The patient was able to perform normal daily activities and returned to work.

Reference

References

1. Lister G. The choice of procedure following thumb amputation. Clin Orthop Relat Res. 1985; 195:45–51.

2. Brunelli F, Vigasio A, Valenti P, Brunelli G. Arterial anatomy and clinical application of the dorsoulnar flap of the thumb. J Hand Surg Am. 1999; 24A:803–11.

3. Terán P, Carnero S, Miranda R, Trillo E, Estefanía M. Refinements in dorsoulnar flap of the thumb: 15 cases. J Hand Surg Am. 2010; 35:1356–9.

4. Chitta M, Malathi L, Joseph A. Cross-finger flap to the thumb: quest for an alternate donor. Indian J Plast Surg. 2020; 53:287–92.

5. Wolfe SW. Green’s operative hand surgery. 6th ed. Philadelphia: Elsevier;2011.

6. Mitchell A, Jason H, Nicholas B. Reconstruction of the traumatized thumb. Plast Reconstr Surg. 2014; 134:1235–45.