Arch Hand Microsurg.  2022 Dec;27(4):300-305. 10.12790/ahm.22.0042.

Functional reconstruction of the thumb by heterotopic thumb-to-thumb replantation and secondary opponensplasty in bilateral amputation in the upper extremities: a case report

• Lee DC
• Lee JY
• Koh SH
• Roh SY
• Lee KJ
• Kim JS

• KMID: 2536216
• DOI: http://doi.org/10.12790/ahm.22.0042

Abstract

In traumatic amputations in the upper extremities, replantation has been commonly attempted with high success rates. However, successful replantation implies both the maintenance of length and good functional outcomes of the restored hand. Since the thumb accounts for 40% to 50% of hand function, the utmost priority is on the salvage of the thumb. In cases when replantation is not feasible, various efforts have been made to replace the thumb, including pollicization of the index finger, toe transfer, lengthening of the thumb stump, and deepening of the first web space. Alternatively, heterotopic thumb-to-thumb replantation has been suggested as a rescue plan in rare circumstances of bilateral amputation in the upper extremities. However, even if heterotopic replantation is successful, there are situations in which a severe crushing injury to the thenar muscles of the recipient’s thumb causes opposition failure of the reconstructed thumb. We report a case of functional reconstruction of the thumb in a rare case of bilateral mangling amputations in the upper extremities, by a heterotopic thumb-to-thumb replantation combined with secondary opponensplasty to compensate for the opposition failure.

Keyword

Heterotopic; Thumb replantation; Opponensplasty; Bilateral amputation

Figure

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  Fig. 1. Initial preoperative photo showing bilateral mangling amputations on the upper extremity. (A) The right forearm was completely amputated at proximal 1/3 level of the forearm with comminution on both ulna and radius. (B) The nondominant left hand had crushing on the thumb, index, middle finger, and palm. The left thumb was subtotally amputated without circulation and severe crushing was found on the thenar muscles; however, the index finger retained blood circulation on the fingertips. On plain radiography, the thumb was amputated at the 1st carpometacarpal joint and the index finger showed bony amputation at proximal phalangeal head level.

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  Fig. 2. Intraoperative photo showing the heterotopic thumb-to-thumb replantation. (A) The right thumb is harvested at the 1st carpometacarpal joint level and replanted to the left hand. (B) The plain radiography taken before thumb replantation and 2 years after surgery, showing the transferred right thumb to the left hand.

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  Fig. 3. Preoperative and intraoperative photo of extensor indicis proprius (EIP) opponensplasty. (A) Preoperative photo taken at 2-year follow-up after the initial thumb replantation, showing limitations in thumb opposition. (B) The EIP tendon was identified through a linear incision over the dorsal ulnar aspect of the 2nd metacarpophalangeal joint. The tendon was detached free from the extensor digitorum communis. (C) Through wide excision of the deep fascia of forearm, the distal part of the muscle belly is gently freed and pulled out. (D) The muscle-tendon unit was tunneled through the subcutaneous border of the ulna and brought out through another incision near the pisiform. (E) Due to the absence of an abductor pollicis brevis, EIP was inserted on the extensor pollicis longus (EPL) tendon. (F) EIP was connected to EPL tendon with a weaving suture using PDS 4-0 (Ethicon Inc., Raritan, NJ, USA).

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  Fig. 4. Follow-up photo of the 10th year after extensor indicis proprius (EIP) opponensplasty taken at the outpatient clinic. (A) Significant improvement in the opposition of thumb was seen, allowing the pinching on the ring and little fingers. (B) Follow-up photo of the 10th year after EIP opponensplasty taken at the outpatient clinic. (B) The radial abduction increased to 55°. (C) The palmar abduction increased to 60°. (D) The patient recovered satisfactory grip power to grab a bottle.

Reference

References

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