A Heterotopic Digital Replantation in an 18-Month-Old Child.
In multiple digital amputations, it is not always possible to replant the same amputated part. In these cases, heterotopic digital replantation is a suitable option in terms of cosmetic and functional outcomes. [1-3]
Previous studies have demonstrated that digital amputations, particularly those secondary to crush injuries, are rare in children when compared to adults. In children, as the vessel diameters are smaller and there is tendency to vasospasm, replantation is more difficult and necessitates experience. However, replantations are accepted as absolute indications in single and multiple digit amputations for the best functional and cosmetic outcomes and may also improve psychological adaptation of the growing child.
In the literature, no cases of heterotopic replantation have been reported within 2 years of age. The current study presents a case of heterotopic replantation which was conducted for a better functional and cosmetic outcome.
An 18-month-old male child who had digital amputation as a result of placing his hand in the ventilator was referred to our clinic from another center that is 3 h away. A total amputation was present at the level of middle phalanx in the ring finger and the level of proximal phalanx in the little finger and a total amputation was detected at the level of distal interphalangeal (DIP) joint in the middle finger in the right hand [Figure 1]. Parents of the patient gave a written and oral consent to surgery. The patient was operated under general anesthesia. On evaluation with microscope in the operating room, it was determined that the ring finger was not suitable for replantation due to the crushing injury; replantation would not be effective, and the success rate would be low through an estimation that it would become smaller after debridement. On evaluation of the little finger amputate under microscope, following debridement of the devitalized structures to the healthy tissue, the vascular and neural structures were found to be intact and it was determined that it could be used as an amputated part instead of the ring finger according to its length and it may be functionally and cosmetically acceptable. Therefore, the decision was made to replant the little finger amputated part to the fourth digit and to repair the little finger stump.
Initially, the bilateral digital arteries, nerves, and two veins were exposed in the amputated part. Then the artery, vein, and nerves that would match up to the ring finger were found. Then the bone was fixated with Kirschner wire, and the flexor and extensor tendons were repaired, respectively. The anastomosis of the bilateral digital arteries and two veins were performed with propylene 11/0 using a microsurgical method, and digital circulation was achieved. Bilateral digital nerves were coaptated.
During postoperative follow-up, dextran was administered as 40-50 mL/day for 5 days and acetylsalicylic acid was administered at 50 mg/day for 1 month. At the postoperative 4th day, a venous problem was observed, and four leeches were placed daily (one leech for every 6 h), and venous drainage was provided. The leech therapy continued for 1 week. The patient was discharged at the postoperative 10th day.
During the postoperative control at the 12th month, the joint motions in the DIP, proximal interphalangeal, and metacarpophalangeal joints were almost complete. The neurological examination (two-point discrimination) could not be conducted as the patient was a child and was not cooperative. However, the functional and cosmetic results were satisfactory [Figures 2 and 3].
Heterotopic digit transplantation to optimize hand function and form in multiple digit amputations was first performed in 1971.  Thereafter, cross digit, hand and foot heterotopic replantations were performed and published. [5,6] However, there is no algorithm that determines the indications for heterotopic digital replantation. Heterotopic replantation is only approved in thumb amputations in routine clinical practice. 
The study of Wei and Colony demonstrated that the repair of the index and middle fingers in multiple digital amputations resulted in better cosmetic outcomes, while the repair of the middle and the ring fingers is important for holding and grasping. In the same study, they demonstrated that the index and the little fingers provided the width of the hand; however, in the presence of only these fingers, a weaker hand with difficulty in controlling the small objects develops. In the present case, crushing amputation occurred on the ring and little fingers obliquely and during preparation for surgery the length of the fingers decreased secondary to debridement. For this reason, the longer amputate of the little finger was anastomosed to the long stump of the ring finger and the length of the ring finger became normal. Although the grasping force could not be measured due to the fact that the patient was a child, it was subjectively observed that the patient had good grasping movements.
In younger age groups, difficulties due to the small diameter of the vessels, technical opportunities, and the presence of an experienced team are important considerations for replantation surgeries.  In particular, the repair of the vein is quite difficult in these cases. In the present case, although two veins were produced, they were thrombosed at the postoperative 3rd day and were recovered with enabling venous drainage with the aid of leech. There were no intra- and post-operative complications in the arterial repair.
Although the reduction in sensation, cold intolerance, and difficulty in cortical adaptation are among the disadvantages of heterotopic replantation, it is an important alternative in multiple digital amputations due to better functional and cosmetic outcomes. [1-3,8] In the current case, as the ring finger amputate was not suitable for replantation, we replanted the little finger amputate with the thought that it would provide stronger grasping force and improved cosmetic result.
Heterotopic replantation is an important method that should be kept in mind in multiple finger amputations which can enable a good cosmetic and functional result, especially in cases where the stump of the amputated finger is not suitable/veya convenient.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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Mehmet Dadaci, Bilsev Ince, Fatma Bilgen (1), Serhat Yarar (2)
Necmettin Erbakan University, Department of Plastic Reconstructive and Aesthetic Surgery, Meram Faculty of Medicine, (2) Clinic of Plastic Reconstructive and Aesthetic Surgery, Konya State Hospital, Konya, (1) Kahramanmaras Sutcu Imam University, Department of Plastic Reconstructive and Aesthetic Surgery Kahramanmaras, Turkey
Address for correspondence: Prof. Mehmet Dadaci, Department of Plastic Reconstructive and Aesthetic Surgery, Meram Faculty of Medicine, Necmettin Erbakan University, 42080 Meram, Konya, Turkey.
How to cite this article: Dadaci M, Ince B, Bilgen F, Yarar S. A heterotopic digital replantation in an 18-month-old child. Turk J Plast Surg 2018;26:174-6.
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|Title Annotation:||Case Report|
|Author:||Dadaci, Mehmet; Ince, Bilsev; Bilgen, Fatma; Yarar, Serhat|
|Publication:||Turkish Journal of Plastic Surgery|
|Date:||Oct 1, 2018|
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