Nehete Rajendra, Nehete Anita, Ghalme Amol, Kulkarni Abhishek, Fidvi Al Iqyan
Division of Plastic Surgery, Vedant Hospital, Nashik, Maharashtra, India.
Indian J Plast Surg. 2024 Jul 23;57(5):342-349. doi: 10.1055/s-0044-1787870. eCollection 2024 Oct.
Hand amputation at the wrist level is severely disabling, especially when bilateral. It is paramount to restore the hand function to the best possible level for the patient's daily living activities, as well as optimal social and occupational rehabilitation. There are various options for restoration of function after amputation at wrist and distal forearm levels including Krukenberg's operation, variations of toe transfers, hand allotransplantation, and prosthesis. Krukenberg's procedure and the reconstruction using toe transfer like Vilkki's procedure or two-toe transfers, restore only the pinch. Hand allotransplantation, although it gives excellent function, has limitations due to the complications of immunosuppression. Functional hand prosthesis, though superior in cosmetic appearance, have again limitations in function, and the cost is prohibitive for most patients in our country. We present the unique case of a bilateral hand amputation at the wrist level reconstructed with three toes and free anterolateral thigh (ALT) flap in a single-stage surgery for each hand. In two stages, the patient had six toes transferred to both hands. All transferred toes and all three free (two ALT and one thoracodorsal artery perforator) flaps survived completely. Three-finger grip (tripod pinch) was thus restored in each hand. The hook grip was also restored well by the reconstructed two fingers. Within 3 months after surgery, the patient could perform all activities of daily living. He resumed his original job with some modification of his work within 6 months postinjury. Hand reconstruction using three toes and a free flap is an excellent option for functional restoration for amputation at the wrist and distal forearm level. It allows an early return to function and good social and professional integration of the patient. This procedure is a potential alternative to expensive prosthesis and allotransplantation for a bilateral hand amputation.
腕部水平的手部截肢会导致严重残疾，双侧截肢时情况尤甚。对于患者的日常生活活动以及最佳的社会和职业康复而言，将手部功能恢复到尽可能好的水平至关重要。腕部和前臂远端截肢后功能恢复有多种选择，包括克鲁肯伯格手术、各种形式的足趾移植、手部异体移植和假肢。克鲁肯伯格手术以及像维尔基手术那样的单足趾移植或双足趾移植重建，仅能恢复捏取功能。手部异体移植虽然功能出色，但由于免疫抑制并发症而存在局限性。功能性手部假肢尽管外观更佳，但功能上也有局限，而且对我国大多数患者来说成本过高。 我们介绍了一例独特的病例，该患者腕部水平双侧手部截肢，每只手均通过单阶段手术用三个足趾和游离股前外侧皮瓣（ALT）进行重建。分两个阶段，患者共有六个足趾移植到双手。 所有移植的足趾以及所有三个游离皮瓣（两个ALT皮瓣和一个胸背动脉穿支皮瓣）均完全存活。每只手均恢复了三指抓握（三脚架捏取）功能。重建的两个手指也很好地恢复了钩状抓握功能。术后3个月内，患者能够进行所有日常生活活动。伤后6个月内，他对工作进行了一些调整后恢复了原工作。 用三个足趾和游离皮瓣进行手部重建是腕部和前臂远端截肢功能恢复的极佳选择。它能使患者早日恢复功能，并实现良好的社会和职业融入。对于双侧手部截肢，该手术是昂贵假肢和异体移植的潜在替代方案。
