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Two cases of multi-level fingertip amputation are presented. In each case, replantation was achieved in a two-stage procedure, involving reattachment, de-epithelialisation and insertion into a palmar pocket in stage 1, followed by removal from the palmar pocket 16 days later. The cases are described and the technique is discussed.
Microsurgical replantation of fingertips is feasible, but multi-level amputations of fingertips are difficult to treat by microsurgical replantation because vessels are severed in several places. The pocket principle
reported a new method of replanting amputated distal phalangeal parts without vascular anastomosis using a subcutaneous pocket. From April 1996, we modified this method and used a palmar subcutaneous pocket for fingertip amputations when vascular anastomosis was not feasible.
We used this method in two cases of multi-level amputation of the fingertip.
1. Operative technique
1.1 First operation
The amputated parts and the amputation stump were washed with normal saline, and the nail was removed. The amputated parts were reattached to the amputation stump without vascular anastomosis, and fractured bone segments were reduced and fixed with Kirschner wires. Kirschner wires were cut as short as possible. After reattachment, the amputated parts were de-epithelialised down to the mid-dermal layer using a scalpel. A 2 cm transverse incision was made in the ipsilateral palm, and the subcutaneous layer was bluntly undermined to make a pocket. The reattached parts were inserted into the pocket and sutured to the palmar skin to prevent the inserted digit from pulling out. Finally, a light compressive gauze dressing was applied.
1.2 Second operation
After 16 days, the replanted fingertip was carefully removed from the palmar pocket, and some active bleeding was noted from the replanted parts. The palmar skin was then sutured. From the day after the second operation, the dressing was changed and a wet dressing was applied. The patients were encouraged to exercise the injured finger.
2. Case reports
2.1 Case 1
A 48-year-old man sustained amputation of his right middle and ring fingers in a cutter of Chinese ravioli. The middle finger was amputated at the level of the nail lunula, and the amputated part was cut transversely into two (Fig. 1(A) and (B)) . The amputated parts were reattached and inserted into a palmar pocket (Fig. 1(C)). At 16 days after the first operation, the fingertip was removed from the pocket. The reattached parts had survived. At 8 weeks postoperatively, a radiograph showed fusion of the distal phalanx (Fig. 1(D)). At 9 months postoperatively, active proximal interphalangeal joint motion of the middle finger ranged from 0 to 95° and static two-point discrimination was 6 mm. The cosmetic aspects were satisfactory (Fig. 1(E) and (F)).
Fig. 1Case 1. (A) The fingertips of the right middle and ring fingers were severed. The amputated part of the middle finger was severed into two parts. (B) Radiograph showing a fracture of the distal phalanx. (C) The reattached fingertip in the palmar pocket. (D) Antero-posterior radiograph at 8 weeks postoperatively. (E) Palmar view of the replanted fingertip and pocket site and (F) dorsal view of the replanted fingertip 9 months postoperatively.
Fig. 1Case 1. (A) The fingertips of the right middle and ring fingers were severed. The amputated part of the middle finger was severed into two parts. (B) Radiograph showing a fracture of the distal phalanx. (C) The reattached fingertip in the palmar pocket. (D) Antero-posterior radiograph at 8 weeks postoperatively. (E) Palmar view of the replanted fingertip and pocket site and (F) dorsal view of the replanted fingertip 9 months postoperatively.
A 50-year-old woman sustained amputation of her right index and middle fingertips in a vegetable slicer. The amputated part of the middle finger was cut transversely into four parts from the tip to the lunule, but two parts (the tip and the third) were lost (Fig. 2(A)) . The tip of the index finger was reattached as a composite graft. The two amputated parts of the middle finger brought in with the patient were reattached and inserted into a palmar pocket (Fig. 2(B)). At 16 days after the first operation, the fingertip was removed from the pocket, and it showed complete recovery 3 weeks later. At 10 months postoperatively active proximal interphalangeal joint motion of the middle finger ranged from 5 to 100°. Static two-point discrimination was 8 mm. The middle finger had a slight nail deformity but no hooked nail deformity (Fig. 2(C) and (D)).
Fig. 2Case 2. (A) The fingertips of the right index and middle fingers were severed. The amputated part of the middle finger was severed into several parts. (B) The reattached fingertip in the palmar pocket. (C) Palmar view of the replanted fingertip and pocket site and (D) dorsal view of the replanted fingertip 10 months postoperatively.
There are various treatments for fingertip amputations. Non-surgical treatment or direct closure of the stump fails to provide an adequate bony platform for nail regeneration and can result in a hooked nail deformity, especially in amputations at the level of the lunule. Microsurgical replantation is the best way to restore finger length and gives the best cosmetic results. However, for multi-level amputation of a fingertip, microsurgical replantation is not commonly used, and the survival of composite grafts in amputations at the level of the lunule is poor, except in children and young adults where the tip is cleanly cut off.
Using the pocket principle, the de-epithelialised composite piece was inserted into a subcutaneous pocket, which provided an additional blood supply. We speculate that, since the replanted fingertip was kept buried during the pocketing period, improved survival may well have resulted from revascularisation via the exposed dermal elements in conjunction with revascularisation via the proximal digital segment.
have used the abdomen. However, in both positions, the wrist, elbow and shoulder joints were immobilised during the pocketing period, and, although patients began to exercise each joint immediately after the finger was removed, some patients complained of stiff joints. Additionally, most patients were anxious about pulling out the pocketed finger. To avoid these problems, we chose the ipsilateral palm as the pocket site. Our success rate was the same as that reported for other pocket sites.
In this method, flexion contracture and sensory loss were concerns. However, in our clinical cases the postoperative sensibility and motion were not significantly different between the palmar pocket method and microsurgical replantation of fingertip amputations.
Evaluation of postoperative sensibility and motion for the treatment of fingertip amputations by palmar pocket method—comparison study among palmar pocket method, Brent method and microsurgical replantation.
Evaluation of postoperative sensibility and motion for the treatment of fingertip amputations by palmar pocket method—comparison study among palmar pocket method, Brent method and microsurgical replantation.
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