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17 Special Types ofFinger Reconstruction
17.5 Reconstruction ofFinger Defects by
Transpositional Replantation
ofAmpuated Finger
Transpositional replantation is also known as heterotopic
replantation and transpositional reconstruction. When the
hand is severely traumatized, the severed nger is partially
damaged and partially intact, but it is unconditionally for
orthotopic replantation. In order to restore the partial function
of the hand as much as possible, the relatively intact nger
body will be retained for waste reuse and replanted in the
required site according to the functional needs. In order to
maximize the reconstruction of the function and utility of the
hand, the secondary operation can be avoided and the pain and
burden of the patient can be relieved through replanting the
less functional severed ngers to reconstruct the more functional important ngers or reconstructing at the proximal limb.
17.5.1 Indications
(a) The patient is young and physically able to endure a long
operation; (b) for patients with higher requirements for nger aesthetics; (c) the damaged ngers, such as the palm and
nger body, are partially damaged, and some of them retain
relatively complete organizational structure, which has certain survival conditions.
17.5.2 Surgical Design
Doctors through agile clinical thinking and accurate microvascular anastomosis technology, after an accurate assessment of the damage situation, make full use of the hand
injury mechanism of complex and serious multi-nger
amputation, or distal limb damage. As a result, orthotopic
replantation cannot be performed, or even after orthotopic
replantation, the main functions of ngers such as pinching,
clamping, grasping, and holding cannot be well restored.
Transpositional replantation of the relatively intact residual
ngers, and nally the relatively satisfactory appearance and
function can be achieved.
17.5.3 Surgical Method
(a) For patients with severed thumbs and unable to ortho-
topic replantation, transpositional replantation of thumb
should be given priority, followed by the order of index
nger, middle nger, ring nger, and little nger.
(b) When selecting the replantation of the severed body,
focus on the nearby part of the joint, and the complete
joint is better. Phalangeal diameter is different, which is
correspondingly larger than the thumb. In the use of
Kirschner wire xation should pay attention to the dorsum which should be at while the dorsal digital vein
anastomosis will have a good vascular bed.
(c) When performing debridement, the tissue should be pre-
served as much as possible, so that the amputated body
would not be too short due to debridement. The dissociation of the blood vessels and nerves of the broken end
should not be too long to avoid pulling and extraction
while the length of the phalanx should be more than
0.5cm shorter than the soft tissue such as tendons, blood
vessels, nerves, and skin.
(d) Bone xation can be performed by longitudinal
Kirschner wire, “8” shaped steel wire, and screw xation. In practice, Kirschner wire longitudinal xation is
simple and reliable that can save operation time, although
it may affect postoperative joint movement.
(e) The rst choice is to suture the extensor or exor tendon
that is less injured than the tendon of the amputated nger. Attention should be paid to the appropriate tension,
do not angle and discount, 3-0 noninvasive needle suture
is used. A deep fascia could be lined in the tendon repair
bed to separate the tendon from the bone junction to
avoid adhesion at the bone xation site.
(f) Proximal veins are easy to be found, mostly dorsal while
the veins of the severed nger are also on the dorsum of
the hand or nger. During the anastomosis, 10–12
stitches can be performed end-to-end anastomosis with
the distal vein with the appropriate diameter. The radial
or ulnar artery is selected to anastomosed with the common digital artery or digital artery of the ectopic replantation nger. However, in the arterial anastomosis, no
matter with the common digital artery or digital artery
anastomosis, there are difculties in diameter disparity,
which can use the end-to-side method, vascular insertion
method and other suture methods to be solved. In addition, if the vessels cannot be directly anastomosed during
the operation, the arteriovenous reconstruction should
be performed by grafting the residual vein or bridging
the forearm vein.
(g) Special attention should be paid to nerve repair, as it is
important for a nger to be successfully replanted to
restore satisfactory function. The nerves on both sides
should be anastomosed as far as possible, and early
recovery is conducive to the recovery of pinching function and early functional exercise. If the nerve defect
cannot be directly anastomosed, the healthy residual
17.5 Reconstruction ofFinger Defects by Transpositional Replantation ofAmpuated Finger
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267
nerve or sural nerve can be transplanted to reconstruct
the sensory function of the nger.
(h) Skin suture should not be too tight, and an indwelling
rubber tablet should be placed for drainage to avoid local
bleeding or hematoma forming pressure on venous
return which can be removed 48 h after the operation.
When dressing, attention should be paid to maintaining
an opponens position and braking with the front and
back plaster braces.
17.5.4 Postoperative Treatment
(a) After the operation, intensive nursing and close observa-
tion of the reconstructed nger should be carried out.
(b) Routine treatment of “three antitherapy” after the
operation.
17.5.5 Operation Characteristics
After the hand suffered from severe trauma, the severed nger, such as the palm and nger, is partially damaged, and
some remaining is relatively intact, which is unconditionally
for orthotopic replantation. In order to restore the partial
function of the hand as much as possible, the relatively intact
nger body will be retained for waste reuse and replanted in
the required area according to the functional needs. The
function and utility of the hand can be reconstructed to the
greatest extent by replanting the inferior severed ngers in
the position of the relatively important ngers, or by reconstructing part of the hand appearance at the proximal limb.
17.5.6 Announcements
(a) The mechanism of injury and the condition of the wound
must be understood, and the prognosis of replantation
surgery should be determined by an experienced
physician.
(b) For such patients with severe nger body compression
and pollution, it is very important to completely remove
the inactive tissue and not to remove too much normal
tissue during emergency debridement, which is very
important to prevent infection and ensure the success of
the surgery.
(c) In the operation of heterotopic explanation, when the
amputated ngers are not separated, it should be noted
that there are thick veins near the dorsal web when dividing the ngers.
(d) During vascular anastomosis, the needle distance and
edge distance must be uniform and accurate, and the
knot should be lifted gently to prevent the anastomosis
from turning inside. The operation should be steady,
light, and fast.
(e) The problem of the different sizes of the nger and the
diameter of the blood vessel will appear in the proximal
and distal ends. It should be adjusted and matched
appropriately according to its anatomical characteristics,
and a variety of vascular anastomosis methods should be
adopted.
(f) Survival after replantation is not the only indicator of
successful replantation. “success” should be dened as a
return to the good appearance and function of the
affected hand. Therefore, after the replanted nger is
survived, functional exercise should begin.
(g) Postoperative nursing is the most important, must let the
patient actively cooperate with the treatment, in order to
obtain the best effect. Careful treatment of drugs, avoiding multi-drug combinations.
17.5.7 Case Description
Case 1 The 38-year-old female patient was admitted to the
hospital for 1 h due to pain and bleeding of the left hand
caused by an injection molding machine in hurty. Physical
examination: She was in good general condition, with stable vital signs. The left wrist joint was severely defective,
only the thumb and the body structure from the distal to the
proximal segment of the ring and little ngers remained
intact, skin and soft tissue avulsion defect of the left wrist,
palm, and second to third ngers, multiple fractures, irregular edges of the tendons, blood vessels, nerves, bleeding,
and the residual ngers were without blood supply. After
debridement under anesthesia, the remained thumb, ring
nger, and little nger were trimmed and then transpositionally replanted to the metacarpus and radius, and xed
with ø1.0mm Kirschner wire. The tendons, blood vessels,
and nerves were anastomosed for repair. The operation was
successful, after the tourniquet relaxed, the reconstructed
ngers were ruddy with moderate tension, wrapped with
the sterile cotton, bulked, and stuffed with the broken cotton gauze around, and she returned to the ward safely.
Routine reconstruction treatment was given after the operation. Two weeks after the operation, the reconstructed ngers survived successfully. Regular follow-up was
conducted to guide functional exercise. The appearance
and function of the reconstructed ngers were satisfactory
(Fig.17.9).
268
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17 Special Types ofFinger Reconstruction
Fig. 17.9 Reconstruction of the left wrist defect by transpositional
replantation of the residual thumb, ring nger, and little nger. (a)
Preoperative lateral view of hand defect. (b) Preoperative palmar view
of hand defect. (c) The palmar view of the reconstructed hand after the
operation. (d) The radial view of the reconstructed hand after the opera-
Case 2 The 20-year-old male patient was admitted to the
hospital for 1.5 h due to pain and bleeding in the right hand
caused by a chainsaw injury. Physical examination: He was
in good general condition, with stable vital signs.
Longitudinal oblique wound on the right hand, ngertip
defect of the index nger, the middle nger was defected
from distal to middle plane of the proximal segment, the ring
and little ngers were amputated, and only partial of the skin
of the ulnar side of the palm connected, and the amputated
nger bodies were complete without blood supply. Irregular
ends of fractures, tendons, blood vessels, and nerves could
be seen in the wound surface that was bleeding, and the
residual ngers had no blood supply. After debridement
under anesthesia, the remained ring nger and little nger
were trimmed and then transpositionally reconstructed the
tion. (e) Preoperative X-ray. (f) Postoperative X-ray. (g) The reconstructed ngers survived 2 weeks after the operation. (h) The extensor
function of the reconstructed ngers 15 months after the operation. (i)
The holding function of the reconstructed ngers 15 months after the
operation
middle and ring ngers, and xed with ø1.0mm Kirschner
wire. The tendons, blood vessels, and nerves were anastomosed for repair. The operation was successful, after the
tourniquet relaxed, the reconstructed ngers were ruddy with
moderate tension, wrapped with the sterile cotton, bulked,
and stuffed with the broken cotton gauze around, and he
returned to the ward safely. Routine reconstruction treatment
was given after the operation. Regular follow-up was conducted to guide functional exercise. The appearance and
function of the reconstructed ngers were satisfactory
(Fig.17.10).
Case 3 The 46-year-old male patient was admitted to the
hospital for 1 h due to pain and bleeding of the right hand
caused by hot stamping of mold. Physical examination: He
17.5 Reconstruction ofFinger Defects by Transpositional Replantation ofAmpuated Finger
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269
d
g
Fig. 17.10 Reconstruction of the right middle and ring ngers by
transpositional replantation of the residual ring nger and little nger.
(a) Preoperative palmar condition of hand defect. (b) Preoperative dorsal condition of hand defect. (c) Preoperative X-ray. (d) Postoperative
X-ray. (e) The palmar view of the reconstructed hand after the opera-
e
h
f
i
tion. (f) The dorsal view of the reconstructed hand after the operation.
(g) The palmar view of the reconstructed hand 12 months after the
operation. (h) The dorsal view of the reconstructed hand 12 months
after the operation. (i) The exor function of the reconstructed hand 12
months after the operation
was in good general condition, with stable vital signs. A longitudinal wound on the right palm (from the second nger
web to the ulnar rasceta), about 7 × 2 cm, with avulsions of
skin and soft tissue from the proximal segment of thumb
with traces of hot pressure, proximal segment defect of the
index nger (severe destruction of metacarpophalangeal
joint), and complete from distal part of proximal segment of
the ring nger without blood circulation. Fracture masses,
for repair. The operation was successful, after the tourniquet
relaxed, the reconstructed nger was ruddy with moderate
tension, wrapped with the sterile cotton, bulked, and stuffed
with the broken cotton gauze around, and he returned to the
ward safely. Routine reconstruction treatment was given
after the operation. Regular follow-up was conducted to
guide functional exercise. The appearance and function of
the reconstructed ngers were satisfactory (Fig.17.11).
tendons, blood vessels, and broken ends of nerves can be
seen in the wound, with irregular wound margins, bleeding,
and poor blood supply of third to fth ngers. After debridement under anesthesia, the remained middle segment of the
index nger was trimmed and then transpositionally reconstructed the thumb, and xed with ø1.0mm Kirschner wires.
The tendons, blood vessels, and nerves were anastomosed
The 53-year-old male patient was admitted to the
Case 4
hospital for 3 h due to pain and bleeding in the right hand
caused by a Lathe injury. Physical examination: He was in
good general condition, with stable vital signs. The proximal
segment of the index nger is destructively severed from the
transverse palmar stria of the right hand. The structure of the
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17 Special Types ofFinger Reconstruction
Fig. 17.11 Reconstruction of the right thumb by transpositional
replantation of the residual index nger. (a) Preoperative palmar condition of hand defect. (b) Preoperative palmar condition of hand defect.
(c) Preoperative dorsal condition of hand defect. (d) The palmar view of
the reconstructed hand after the operation. (e) The dorsal view of the
severed middle and little ngers was relatively intact and
connected by the tendons, blood vessels, and nerves torn
from the proximal end. Multiple skin contusions, tendon,
blood vessel, and the nerve torn seriously of the ring nger.
Most of the ulnar side of the palm was defective, and serious
defects from the wrist. The thumb and rst nger web were
intact. Fracture masses, tendons, blood vessels, and broken
ends of nerves can be seen in the wound, with irregular
wound margins, and bleeding. The residual ngers were
without blood supply. After debridement under anesthesia,
the remained ring nger and little nger were trimmed and
reconstructed hand after the operation. (f) The palmar view of the
reconstructed hand 3 months after the operation. (g) The dorsal view of
the reconstructed hand 3 months after the operation. (h) Preoperative
X-ray. (i) Postoperative X-ray
then transpositionally reconstructed the middle and ring n-
gers, and xed with ø1.0mm Kirschner wire. The tendons,
blood vessels, and nerves were anastomosed for repair. The
operation was successful, after the tourniquet relaxed, the
reconstructed ngers were ruddy with moderate tension,
wrapped with the sterile cotton, bulked, and stuffed with the
broken cotton gauze around, and he returned to the ward
safely. Routine reconstruction treatment was given after the
operation. Regular follow-up was conducted to guide func-
tional exercise. The appearance and function of the recon-
structed ngers were satisfactory (Fig.17.12).
17.5 Reconstruction ofFinger Defects by Transpositional Replantation ofAmpuated Finger
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271
Fig. 17.12 Reconstruction of the right-hand function by transpositional replantation of the residual middle nger and little nger. (a)
Preoperative palmar condition of hand defect. (b) Preoperative dorsal
condition of hand defect. (c) Preoperative X-ray. (d) Postoperative
X-ray. (e) The palmar view of the reconstructed hand 2 weeks after the
Case 5 The 26-year-old male patient was admitted to the
hospital in emergency due to pain and bleeding of the right
hand caused by a punch injury. Physical examination: He
was in good general condition, with stable vital signs. In the
right hand, the thumb was missing, the index nger was
amputated, and the rst and second metacarpal bones and
their skin and soft tissue were defective. After debridement
under anesthesia, the remained index nger was trimmed
and then transpositionally reconstructed the thumb, and xed
with ø1.0 mm Kirschner wire. The rst nger web was
operation. (f) The dorsal view of the reconstructed hand 2 weeks after
the operation. (g) The palmar view of the reconstructed hand 18 months
after the operation. (h) The dorsal view of the reconstructed hand 18
months after the operation. (i) The exor function of the reconstructed
hand 18 months after the operation
repaired by distal radial artery perforator ap of the ipsilat-
eral foreare, and the donor site was covered by a free skin
graft. The operation was successful, after the tourniquet
relaxed, the reconstructed nger was ruddy with moderate
tension, wrapped with the sterile cotton, bulked, and stuffed
with the broken cotton gauze around, and he returned to the
ward safely. Routine reconstruction treatment was given
after the operation. Regular follow-up was conducted to
guide functional exercise. The appearance and function of
the reconstructed nger were satisfactory (Fig.17.13).
272
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17 Special Types ofFinger Reconstruction
j
Fig. 17.13 Reconstruction of the right thumb by transpositional
replantation of the residual index nger. (a) Preoperative palmar condition of hand defect. (b) Preoperative dorsal condition of hand defect. (c)
Preoperative condition of the index nger. (d) The palmar view of the
reconstructed thumb after the operation. (e) Design of the ap. (f)
Dissociation of the ap. (g) The palmar view of the reconstructed hand
15 days after the operation. (h) The dorsal view of the reconstructed
hand and donor site 15 days after the operation. (i) The dorsal view of
the reconstructed hand and donor site 6 months after the operation. (j)
The function of the reconstructed hand 6 months after the operation
17.6 Temporary Heterotopic Replantation (Reconstruction) ofSevered Fingers
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273
17.6 Temporary Heterotopic Replantation
(Reconstruction) ofSevered Fingers
When the nger is amputated, the integrity of the distal part
of the nger is good while the proximal part is unconditionally replanted due to serious injury or poor general condition, the distal part of the nger can be temporarily
heterotopic replanted in other parts of the body. The healthy
arteries and veins in this part provide a stable blood supply
and nutrition for the severed nger body temporarily. After
the general condition and the proximal injury, the wound
improves, the heterotopic replanted nger body will be transplanted back to the original position, and the purpose of
recovering the appearance and function of the nger body
would be achieved by repairing the blood vessels, nerves,
bones, tendon and other tissues of the nger body. This
method of replantation is called temporary heterotopic
replantation.
In 1986, Godina etal. (1986) proposed that the chest wall
could be the accepting site for severed limbs when the proximal limbs were not in a good condition, which made microsurgery feasible for ectopic implantation. Chernofsky and
Sauer (1990) ectopically transplanted a severed limb forearm
to the abdomen and successfully replanted it to the in-situ
position after 11 weeks in 1990. Hallock (1992) suggested
that the upper abdominal blood vessels could be used to keep
a single severed nger alive. Miao Kaixi successfully hetertopically implanted the second to fth ngers with nger
webs to the foot back in 1992. Gao Weiyang carried out the
successful hetertopically implantation of a severed nger to
the groin in 1996. This method, of course, expands the indications for the replantation of severed ngers, which can
save the functions of the hand as far as possible.
17.6.1 Indications
ing, clamping, grasping, and grasping cannot be ensured
successfully after orthotopic replantation. Emergency heterotopic replantation of the residual limb. Temporary blood
circulation and other supplies were obtained to ensure the
effective survival of the residual nger. After 2 weeks, the
body was restored to a stable state, and the surviving residual
limb was transplanted back to its original position again. In
severe cases, tissue transplantation was required to cooperate
with repair and reconstruction, so as to achieve the reconstruction of relatively satisfactory limb morphology and
function.
17.6.3 Surgical Method
(a) The operation should be carried out in groups, one group
to take the debridement for the proximal and distal parts
of the severed nger, the other group to design the
accepting site, ap, repair the ectopic nger, etc.
(b) The diameter of the accepting vessel and the heterotopic
nger vessel should be the same and the anastomosis
should be performed under a ×8 microscope.
(c) The nerves can be matched in the second phase.
(d) Depending on the soft-tissue defect, the nger could be
ectopically replanted with some soft tissue. If the soft-
tissue defect is to be repaired with an adjacent tissue
ap, pedicle amputation should be carried out.
(e) Design the incision at the accepting site and separate the
vessels that should be anastomosed under a microscope
according to the principle of an arteriovenous ratio of
1:2. The vascular defect can be solved by vessel
transplantation.
(f) Find the nerve end in the severed nger and anastomose
it with the nerve at the accepting site.
(g) Repair the soft-tissue defect with the ap of the ectopic
implantation site.
(a) The patient is young; (b) Be physically able to endure a
long operation; (c) For patients with higher requirements for
nger aesthetics; (d) The injured hand or ngers are partially
damaged, which means partial tissue structure is relatively
complete, and there are blood vessels, nerves and other survival conditions for anastomosis.
17.6.4 Postoperative Treatment
(a) After the operation, intensive nursing and close observa-
tion of the reconstructed nger should be carried out.
(b) Routine treatment of “three antitherapy” after the
operation.
17.6.2 Surgical Design
17.6.5 Operation Characteristics
First of all, doctors should judge the damaged situation and
make an accurate assessment based on their own quick thinking and exquisite micro-vascular anastomosis technology.
Due to serious hand injury and pollution, it leads to unconditional emergency orthotopic replantation, or even if pinch-
After severe trauma, part of the severed hand, nger, and
other parts are damaged and relatively intact. Such injury
and pollution lead to unconditional direct in-situ reconstruction in an emergency.
274
17 Special Types ofFinger Reconstruction
In order to restore the function of the injured hand as
much as possible, the residual limbs should be selected for
temporary heterotopic replantation where is convenient.
17.6.6 Announcements
1. In the case of completely severed ngers combined with
a serious compound injury that cannot tolerate long-term
replantation surgery, the ngers can be hetertopically
implanted after debridement and replanted in a second
phase.
2. Ectopic implantation should be considered when the
important nger is completely severed, whose distal part
is complete, and the proximal is seriously damaged.
Replantation in situ or transposition is not permitted; otherwise, the function will not be good.
3. The principle for the choice of accepting site is:
(a) The location is concealed and the effect is small.
(b) It is easy to x the severed nger. The diameter of the
accepting vessel and the heterotopic nger vessel
should be the same, constant, easily separated, and
obtained. There should be a nerve for anastomosis
that does not affect body function.
(c) There should be a ap to repair the soft tissue defect.
(d) The most commonly used sites are the abdomen, the
thigh, the calf, etc.
17.6.7 Case Description
Case 1 The 25-year-old male patient was admitted to the
hospital for 2 h due to pain and bleeding of destructive avulsion of the skin and soft tissue of the left hand caused by
high-speed machine injury. Physical examination: He was in
good general condition, with stable vital signs. Large area of
skin and soft tissue defect of left forearm and hand, second to
fth ngers defect, skin defect of the thumb, only nail bed
remained, bone exposed, seriously polluted. The avulsed
skin and soft tissue were fragmentary, and the avulsed blood
vessels, nerves, and tendons were like hemp silk, with serious pollution and no conditions for replanting. After admission, routine preoperative preparation for reconstruction was
given, and surgical contraindications were excluded. Wound
debridement and VSD operation were performed under general anesthesia in emergency. Two weeks after the operation,
the wound was expanded under general anesthesia at a
selected time. The design of the donor sites of iliac abdomen,
bilateral thigh, and foot was performed. The left iliac abdominal ap, the bilateral anterolateral thigh aps, the great toenail ap combined with dorsal foot ap and the second toe
were taken to repair the wound and reconstruct nger function. During the operation, vascular series anastomosis was
adopted, and the free tissue of the foot was hetertopically
replanted with vascular pedicle to foster and reconstruct the
nger. After the foster thumb survived, vascular pedicle
amputation of the thumb was performed under general anesthesia in the second stage. Routine reconstruction treatment
was given after the operation. The reconstructed nger survived successfully. Regular follow-up was conducted to
guide functional exercise. The appearance and function of
the reconstructed nger were satisfactory (Fig.17.14).
Case 2 The 18-year-old male patient was admitted to the
hospital for 2 h due to pain and bleeding of destructive
avulsion of the skin and soft tissue of the left thumb caused
by noodle press. Physical examination: He was in good general condition, with stable vital signs. The left thumb was
torn off from the metacarpophalangeal joint, and the digital
nerves and digital arteries were pulled out about 3cm from
the proximal end. The exor tendon was continuous; the distal nger body was intact. The skin of the proximal palm was
exfoliated and partially missing, and there was no anastomosis condition for the proximal arteries and veins. After admission, the skin with mild proximal contusion was replanted in
situ, and the pedicled abdominal ap (6 × 8 cm) was designed
to repair the dorsal defect of the hand. At the same time, the
distal intact nger body was transferred and anastomosed to
the radial side of the proximal segment of the right index
nger for temporary heterotopic replantation. Three weeks
after the operation, the left thumb was reconstructed by the
surviving foster nger under general anesthesia in the second
stage. Routine reconstruction treatment was given after the
operation. The reconstructed nger survived successfully.
Regular follow-up was conducted to guide functional
exercise for 12 months. The appearance and function of the
reconstructed nger were satisfactory (Fig.17.15).
Case 3 The 34-year-old female patient was admitted to the
hospital for 8 h due to pain and bleeding of the severed left
thumb caused by a rapidly working machine. Physical examination: she was in good general condition, with stable vital
signs. After the dressing was opened, it was found that the
left thumb was missing, the wound surface was seriously
polluted and bleeding slowly, and the skin defect of the
stump of the thumb was accompanied by bone exposure. The
17.6 Temporary Heterotopic Replantation (Reconstruction) ofSevered Fingers
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Fig. 17.14 Reconstruction of the left forearm and left hand avulsed
wound by temporary heterotopic replantation of the second toe. (a)
Preoperative condition of the left upper limb. (b) Preoperative design of
the donor’s foot. (c) Preoperative design of the left iliac abdominal ap,
the bilateral anterolateral thigh aps. (d) Dissociation of the great toenail ap and the second toe. (e) Dissociation of the left anterolateral
thigh ap. (f) Dissociation of the right anterolateral thigh ap. (g)
Temporary heterotopic reconstruction. (h) The appearance of the reconstructed hand 4 weeks after the operation. (i) The appearance of the
reconstructed hand 16 months after the operation. (j) The appearance of
the reconstructed hand 16 months after the operation. (k) The function
of the reconstructed hand 30 months after the operation. (l) Working
condition of the affected limb 30 months after the operation
i
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