Thumb loss is always a devastating injury. Microsurgical replantation has afforded patients and hand surgeons with the opportunity to restore excellent function in many of these injuries. However, replantation is not always a viable treatment alternative, nor is it always the best alternative. The authors present an excellent educational treatise on the alternatives to replantation of the amputated thumb. Indications for alternative treatments are presented and decision criteria are outlined. Requirements for a successful thumb reconstruction are presented: sensation, lack of pain at the tip, stability of the IP and MCP joints, mobility, adequate strength for some pinch and grip, correct positioning of the thumb with an adequate webspace, and CMC joint mobility with intrinsic function for prehension. A treatment algorithm is presented, based on the level of the amputation. Nonmicrosurgical techniques are discussed with indications and technical descriptions of the procedures. These include revision, palmar advancement, local flaps, and distant flaps. Neurovascular island flaps are technically outlined with excellent diagrams. Distraction lengthening of the metacarpal is mentioned and radiographically depicted for clarity. Osteoplastic thumb reconstructions are described with variations for providing enhanced contour and sensation. Prosthetics are also covered, but with a largely negative bias given their poor record of patient use in many studies. Microvascular techniques short of replantation are also presented including pollicization, toe-to-thumb and wrap-around flaps and heterotopic soft tissue/joint transfers. Outcomes are discussed based on the level of the amputation.
The authors present an excellent basic educational overview of treatment alternatives to replantation of the amputated thumb. Indications and technical details prevail, which makes this an extremely practical tool. It is a good reference to guide treating physicians in selection of a given procedure and the technical details important for success.