Online First Indian J Case Reports 1
Replantation of en-bloc amputation of all ve toes: A very rare case
Abhishek Ghosh1, Jayakumar R2
From 1Consultant, Department of Microvascular and Cosmetic surgery, Poona Hospital, Noble Hospital, Pune, 2Head of Department, Department of
Plastic and Microvascular Surgery, Specialist Hospital, Kochi, India.
Correspondence to: Dr Abhishek Ghosh, B-4,201, Silver Oak society, Kalyaninagar, Pune, Maharashtra-411006, India.
Received - 21 March 2019 Initial Review - 05 April 2019 Accepted - 16 July 2019
Loss of all toes not only causes tremendous psychological impact but also causes a signicant functional defect. There is no reported
case of replantation ofen bloc amputation of all ve toes and very few papers on single or double toe replantations hence we had to
rely on our experiences and logic to salvage the amputated part. Here, we report the case of replantation of en-bloc amputation of all
ve toes in a 16-year-old male. The purpose of this report is to share the authors’ experience with en bloc toe replantation. Successful
replantation goes a long way in mitigating the psychological and functional trauma of the patient.
Keywords: Amputation, En Bloc toe replantation, Microsurgery.
En bloc multiple toe amputation is a devastating injury
both for the patient and his family resulting in not only
functional impairment but also tremendous psychological
trauma. The crushing element involved in the accident makes
usual techniques in replantation unsuitable. There is no publication
describing replantation in en bloc amputation of all ve toes in the
literature and very few publications of successful toe replant [1-
4]. Hence, new ideas and methods had to be evolved to tackle this
problem. We report the case of replantation of en-bloc amputation
of all ve toes in a 16-year-old male.
A 16-year-old male came to the department with en bloc
amputation of all the toes at the metatarsophalangeal joint level
on 15th April 2011 (Fig. 1). His foot had accidentally gone in
the wheel of a running motorcycle during a collision of two
motorcycles. He was taken to the local hospital where the part
was preserved properly and sent to our institute.
On examination, the vitals were stable. The warm ischaemia
time was 1 hour and the cold ischemia time was around 2 hours.
The patient was assessed for concomitant injuries. The amputated
part was assessed and as the en bloc amputation of all ve toes was
due to crush avulsion type of injury, there was extensive damage
to the vessels and the local tissues at the site of amputation. The
amputated stump also showed extensive crushing of the tissues
and the vessels in the zone of amputation. But despite the crushed
and degloving nature of the injury, it was decided that an attempt
be made to replant the toes.
The patient was resuscitated and the part sent to the OR for
dissection and tagging of the neurovascular structures. K wires
were passed in the toe phalanges for xation. The patient was
anesthetised and the wound explored. The dorsal digital arch was
found to be avulsed and injured. Thus the dorsalis pedis artery
was identied just distal to the branch to the plantar arch. Dorsal
veins were identied, dissected and tagged. Both dorsal and
plantar digital nerves were dissected and tagged. A Y-shaped vein
graft was harvested from the opposite side foot. Sural nerve graft
was harvested from the opposite leg.
The distal part was then xed to the stump with K wires across
the metatarsophalangeal joints. Then the vascular anastomosis
was started with anastomosis of the dorsalis pedis artery with the
common digital arteries of the rst and second web spaces with a
Y shaped vein graft using 10-0 nylon under the microscope. The
toes pinked up and venous return was noted. Four dorsal veins
were anastomosed with the use of vein grafts with 10-0 nylon
under the microscope. Dorsal and plantar digital nerves were
co-apted with 10-0 nylon under a microscope with nerve grafts.
Postoperatively, the patient was observed in the microsurgical
ICU for ve days. The fth toe showed ischemic changes. Heparin
and dextran were given for ve days. The fth toe was allowed
to separate following dry gangrene. The resultant wound was
Figure 1: Preoperative picture of the (a) amputated part and (b)
Ghosh & Jayakumar Replantation of en-bloc amputation of all ve toes
Online First Indian J Case Reports 2
dressed and covered with split-thickness skin graft. The patient
was mobilised on a walker after two weeks and was started
on gradual weight bearing on the heels from the third week.
The K wires were removed after 8 weeks. The patient developed
a normal gait and has attained the full protective sensation of the
toes at 4 months. He is able to wear normal footwear and is fully
satised with the outcome (Fig. 2).
Replantation of the composite distal parts prove to be a daunting
challenge and is made more difcult if there is an associated
crush element to the injury. Toe amputations are seldom taken
up for replantation due to fear of impending failure.The overall
survival rate even when attempted is quite low and the main
cause of failure is seen as arterial insufciency due to vasospasm
in these small vessels . When the great toe amputation is
associated with injury to lateral toes the survival rate drastically
reduces . This makes replantation of en bloc amputation of
toes very difcult and rare. There have been reports of successful
replantation of en bloc amputation of two and three toes [5,6] but
no report of successful replantation of en bloc amputation of all
ve toes till date.
The crushing and degloving nature of the accident meant that
both the proximal stump vessels and distal part vessels were in
the zone of injury and not suitable for anastomosis. The dorsal
digital arch was also disrupted and not usable. It was then decided
to adopt a novel method using a Y-shaped vein graft connecting
the dorsalis pedis artery to the common digital arteries of the rst
and second web spaces (Fig. 3). It was hypothesized that the 4th
and possibly the fth toe will get its blood supply through the
connections between the arteries of the third, fourth and fth toes.
Multiple dorsal veins and both dorsal and plantar digital nerves
were also connected using grafts.
Conventional techniques do not provide an answer to these
challenging problems. The small vessel calibre at the amputation
site and also the fact that the vessels are in the zone of injury
makes them unsuitable for anastomosis primarily.The use of vein
grafts to connect a distant vascular source to the amputated part
and also using the unique arterial continuity between adjacent
toes helps to solve this seemingly insurmountable problem. The
dorsalis pedis artery near the origin is away from the zone of injury
and is less prone to vasospasm as compared to the digital arteries
of the toes. Hence, using a vein graft to connect the dorsalis pedis
artery to the digital arteries in the distal amputated part provides
for a much more reliable vascular supply to the replanted part.
The use of a Y shaped vein graft to connect two common digital
arteries using a single source helps to vascularise the entire en
bloc amputated ve toes. Multiple venous anastomoses should
be done to prevent venous congestion. It is possible to salvage
en bloc amputation of all ve toes with proper planning and
Replantation of distal parts should always be attempted and can
give good results alleviating the patient of the psychological
trauma of losing all his toes.
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replantation: a ten-year follow-up. J Reconstr Microsurg. 2006;22:79-86.
3. Ademoğlu Y, Ada S, Kaplan I. Should the amputations of the great toe be
replanted?.Foot Ankle Int. 2000;21:673-9.
4. Lin CH, Lin CH, Sassu P, Hsu CC, Lin YT, Wei FC. Replantation of the
great toe: review of 20 cases. Plast Reconstr Surg. 2008;122:806-12.
5. Sabhapathy R, Mohan D, Singh SB, Venkatramani H. Replantation of great
and second toe: a worthwhile effort. Plast Reconstr Surg. 2000;106:229-30
6. E Beimer, W Duspiva. Reconstructive Microvascular Surgery. Publisher:
Springer Verlag. 2012;101-2.
Funding: None; Conict of Interest: None Stated.
How to cite this article: Ghosh A, Jayakumar R. Replantation of en-bloc
amputation of all ve toes: a very rare case. Indian J Case Reports. 2019;
01-Aug [Epub ahead of print].
Figure 3: Diagrammatic representation of the Y-shaped vein graft
used in the replantation
Figure 2: Four months postoperative picture showing well
vascularied toes and healed wound