Functional and esthetic reconstruction of a mutilated hand using multiple toe transfers and iliac osteocutaneous flap: a case report

Restorative Strategies for Bilateral Mutilated Hands in a Secondary Care Level: A Report of a Case in Mexico

This case report aims to delineate the challenges and management strategies for a patient with bilateral mutilated hands within a secondary care level in Mexico, contributing to medical literature and potentially guiding future patient care. Mutilated hands represent a significant surgical and rehabilitative challenge due to the profound structural damage they cause, leading to considerable functional impairment and psychological distress. The complexity of these injuries necessitates a multidisciplinary approach, particularly in resource-constrained settings. We present a case of a 45-year-old male with no prior significant medical history who sustained bilateral mutilated hands from an industrial accident involving hot rollers. The patient underwent extensive surgical reconstruction and postoperative care, facing complications such as skin graft integration issues and infections, which required a multidisciplinary treatment approach.

Bilateral Metacarpal Hands: Reconstruction With 6 Toe Transfers

Background: Bilateral metacarpal hand injuries are extremely rare, but probably represent the most difficult reconstructive challenge in hand surgery. Methods: We discuss the various options for metacarpal hand reconstruction, including the Krukenberg procedure, bionic prostheses, multiple toe-to-hand transfers, and possibly hand transplantation, and present the long-term functional outcomes, gait analysis, and psychological evaluation after a 4-stage reconstruction of bilateral metacarpal hands in a child using 6 toe-to-hand transfers-bilateral great toe transfers to reconstruct both thumbs and bilateral combined second-third monobloc transfers to reconstruct 2 fingers in each hand. Results: Reconstruction of bilateral metacarpal hands with 6 toe transfers yielded excellent functional results and patient satisfaction. Conclusions: Bilateral metacarpal hand injuries result in a devastating functional deficit and a major psychological impact. Multiple toe transfers (4, 5, or 6) provide an excellent reconstructive outcome with acceptable donor site morbidity.

Thoracoumbilical Flap: Anatomy, Technique, and Clinical Applications in Upper Limb Reconstruction in the Era of Microvascular Surgery

Purpose

Microvascular reconstruction is the standard of care for salvage of soft tissue defects in complex upper extremity due to their distinct advantages over the pedicled flaps. However, in the era of microsurgery, pedicled flaps have an acceptable significant role for reconstruction of complex soft tissue defects. The authors aim to demonstrate the versatility of pedicled thoracoumbilical flap (TUF) in selected clinical scenarios.

Patients and Methods

Retrospective analysis of patients who underwent TUF for upper limb posttraumatic reconstruction was performed between January 2016 and October 2017. The demographic details, etiology, wound parameters, clinical circumstances, and complications were recorded.

Results

Ten patients were included in the retrospective case series. Out of them, nine of the patients had critical issues, which justified a pedicled TUF over free flap. The critical issues were severe comorbid illnesses ( n = 3), the paucity of recipient vessels ( n = 1), salvage of hand replant and revascularization ( n = 2), circumferential degloving injury to the multiple fingers and palm ( n = 1), coverage for metacarpal hand ( n = 1), and extensive scarring at the surgical site ( n = 1). Mean age was 34.4 years (range: 11-70 years), six of them were males, and four were females. Two patients had infections resulting in wound gaping. One of the patients had flap tip necrosis.

Conclusion

Pedicled flaps have a significant acceptable role in this era of microsurgery, and a pedicled TUF is a versatile option for coverage of complex soft tissue defects of the forearm, wrist, hand, and fingers.

Level of Evidence

This is a level IV, therapeutic, and retrospective study.

Secondary Thumb Reconstruction in a Mutilated Hand

The thumb plays an integral role in hand function. Traumatic amputation results in significant morbidity. With loss of the thumb, up to a 40% reduction in hand function may result. Thumb replantation must be attempted when possible. The goals of thumb reconstruction are to replicate normal function as closely as possible, minimize donor site morbidity, and expedite recovery. In the setting of a mutilated hand, the status of the remaining digits must be carefully assessed. Toe transfers, osteoplastic thumb reconstruction, and pollicization are commonly used. This article summarizes the indications and technical considerations in addressing the deficiencies after thumb amputation.

Defining the Indications of Pedicled Groin and Abdominal Flaps in Hand Reconstruction in the Current Microsurgery Era

Three decades ago, pedicled flaps from the groin and abdomen were the workhorses in hand and forearm reconstruction. These pedicled flaps have several disadvantages including patient discomfort, stiffness, the need for flap division, and the inability to elevate the hand after acute trauma. Hence it is not surprising that free flap reconstruction has become the method of choice in coverage of complex hand and forearm defects. Despite this, pedicled flaps may still be indicated in the current era of microsurgery. Based on a review of the literature and the author's experience, the current review defines these indications as follows: complex defects in children aged less than 2 years; coverage of digital stump defects in preparation for toe-to-hand transfer; high-voltage electric burns with the hand surviving on collateral blood supply; salvage of the thumb ray in high-voltage electric burns with concurrent thrombosis of the radial artery; mutilating hand injuries; length preservation of multiple digital amputations in manual workers; and multiple defects within the digits, hand, or forearm. These indications are discussed along with clinical examples.

Principles for the management of toe-to-hand transfer in reexploration: toe salvage with a tubed groin flap in the last step

Failure of the transferred toe in toe-to-hand transplantations is a catastrophe and a devastating complication for both the patient and the reconstructive surgeon, as in all microvascular tissue transfers. Management of the toe transfer in the case of reexploration is still a challenging issue, even for experienced microsurgeons. In this report, basic principles for a successful outcome are proposed, based on experience with more than 500 toe-to-hand transfers. Although the requirements for each case may vary, technical details and some basic salvage strategies receive special emphasis. When faced with a problem, the first step should be focused on perceiving the problem differently from under completely normal conditions. The problem may occur at any stage of the procedure. The basic orientations are focused on vasospasm, a thrombus inside the lumen, possible intimal damage that may be caused during the surgery or by a thrombus, or technical failures regarding anastomoses. After all possible revisional procedures have been carried out, if the proper arterial inflow and/or venous outflow are still not provided, or if the general health status of the patient is no longer suitable for additional lengthy procedures, the tubed groin flap can be used to salvage the transferred toe. Between 1996-2004, eight tubed groin flaps were used to salvage transferred toes in the last step of the revisional procedure, with satisfactory results. In conclusion, close follow-up and prompt reexploration when needed are both essential to salvaging transferred toes. Proper surgical strategies and decision-making in reexploration are highly important factors in achieving a successful outcome. In prolonged and recurrent revisional steps, the creation of a tubed flap by means of a reliable flap is an effective procedure as the last step of the salvage procedure.

Single versus double arterial anastomoses in combined second- and third-toe transplantation

Combined second and third toe transplantation is one good option for reconstruction of multiple digit amputation. However, the use of one or two arteries for pedicle anastomoses, which may influence the vascular complication and success rate, has never been addressed in the literature. This study includes a retrospective review of 57 combined second and third toe transplantation in 54 patients performed from February of 1983 through December of 1996. Group I, composed of 41 transplantations, underwent one arterial anastomosis, and group II, composed of 16 transplantations, underwent double arterial anastomoses during surgery if there were two recipient arteries available or whenever the second and third toes showed inadequate blood perfusion after one arterial anastomosis. In group I, 10 transplantations (24.4 percent) required re-exploration with a success rate of 92.7 percent (38 out of 41 transplantations). In group II, only one transplantation (6.2 percent) required re-exploration with successful flap salvage. The success rate was 100 percent for group II. Because the re-exploration and success rates between groups I and II were not statistically significant according to two-tailed Fisher's exact test, the combined second and third toe transplantation is a reliable procedure using either single or double arterial anastomoses.